Received: 21 December 2020

DOI: 10.1002/smi.3096

REVIEW ARTICLE
- -
Revised: 15 July 2021 Accepted: 16 August 2021

Positive interventions for stress‐related difficulties: A

systematic review of randomized and non‐randomized trials

Sébastien Ferrandez | Andrea Soubelet | Louna Vankenhove

Université Côte d’Azur, CoBTeK Lab, Nice,

France Abstract
The effectiveness of positive psychology interventions in the treatment of stress‐
Correspondence
Sébastien Ferrandez, Université Côte d’Azur,
related difficulties have not been well established. To estimate the effectiveness
CoBTeK Lab, Nice, France. of positive psychology interventions on the reduction of stress‐related symptoms, a
Email: sebastien.ferrandez@univ-cotedazur.fr
systematic review using PubMed, Scopus, Wiley, Psychinfo, Cochrane and Sage
databases with no limitation of date of publication was conducted. We identified
additional studies by searching positive psychology reviews and academic books.
Only studies trying positive interventions that included measures of anxiety, stress,
or posttraumatic stress disorder symptoms were reviewed. We extracted data using
predefined data fields and study quality was assessed with the National Institutes of
Health study quality assessment tools. Twenty‐nine records were included in this
study: 23 controlled trials and six pre‐post studies. Every study showed significant
improvement in at least one dimension. Several studies reported improvements in
well‐being as well. This review shows promising results of positive psychology in-
terventions as a treatment for stress‐related difficulties. However, important
methodological biases and strong heterogeneity among the studies highlight the
need for replication and better validation of positive psychology interventions.

KEYWORDS
anxiety, positive psychology, stress, traumatic stress, treatment

1 | INTRODUCTION improve the caretaking of mental disorders (Shankland, 2014). PP is

Stressful situations are ubiquitous in human life. Stress can be viewed
as ‘a particular relationship between the person and the environment
that is appraised by the person as taxing or exceeding his or her
resources and endangering his or her well‐being’ (Lazarus & Folk-
man, 1984, p. 19). Stress can lead to a wide range of psychological
outcomes, including anxiety (Endler & Kocovski, 2001), depressive
symptoms (Hammen, 2005), or post‐traumatic stress symptoms
(PTSS) (Resnick et al., 1992).
Several evidence‐based treatments already exist to reduce stress
in healthy and pathological subjects, including mindfulness in-
‘the study of the conditions and processes that contribute to the
flourishing or optimal functioning of people, groups, and institutions’
(Gable & Haidt, 2005). It was developed to respond to an imbalance
in psychology studies. Indeed, research has focused mainly on defi-
cits, difficulties, and pathologies, while PP aims to develop strengths,
values, and positive aspects of adversity without denying their
negative counterparts. PP therefore acts as a complement to deficit‐
focused approaches of psychopathology by striving ‘toward an un-
derstanding of the complete human condition’ (Gable & Haidt, 2005).
Its practice is based on empirically tested tools to attain this goal.
Many processes, states, and functions usually investigated by

-
terventions (Grossman et al., 2004) and stress reduction training PP are related to stress and anxiety. For example, resilience can be
(Kröll et al., 2017). One of the goals of positive psychology (PP) is to viewed as the process in which one adapts positively in adversity

Stress and Health. 2021;1–12. wileyonlinelibrary.com/journal/smi © 2021 John Wiley & Sons Ltd. 1
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- FERRANDEZ
(Windle, 2010); well‐being is broadly defined as the optimal psy-
chological functioning; and posttraumatic growth involves “positive
changes in individuals that occur as the result of attempts to cope
in the aftermath of traumatic life events” (Tedeschi
Calhoun, 2004).
Numerous PP interventions currently exist. PP interventions are
interventions that aim to use positive resources as protective factors
and develop well‐being. There are also well‐established and emerging
areas of intervention (Parks & Schueller, 2014). Established areas (for
instance, gratitude, forgiveness, and meaning in life are well‐
established areas) have led to well‐validated interventions such as
the Three Good Things (Emmons & McCullough, 2003) or forgiveness
interventions (Wade & Tittler, 2020). There are varying types of
emerging interventions, including interventions based on virtues or
strengths of character like creativity, patience, courage, or the 7
Humor Habits Program (McGhee, 2010). Many of these interventions
have shown good results in the development of well‐being and the
reduction of depressive symptoms (Sin & Lyubomirsky, 2009). Well‐
established interventions such as those based on gratitude seem to
bear consistent positive results and improve optimism, gratitude,
positive affects, well‐being, and prosocial behaviours (Parks &
Schueller, 2014). For instance, positive psychotherapy is based on the
principles of positive psychology. Its practice relies on the develop-
ment of strengths and positive appraisal of events. Positive psycho-
therapy seems to show positive effects on depression, social skills,
happiness, and anxiety (Rashid, 2014).
While research has mainly focused on the effectiveness of PP
interventions on depressive symptoms and well‐being (Bolier
et al., 2013; Sin & Lyubomirsky, 2009), there is no review that has
assessed the effectiveness of PP interventions on stress, anxiety,
and posttraumatic stress disorder (PTSD) outcomes. We know that
many positive resources of patients such as hope or gratitude can
contribute to protecting them from stress and promoting resilience
(Hiraoka et al., 2015; Martínez‐Martí & Ruch, 2017). While some
patients do not respond to treatment, or simply drop out,
exploiting those resources may achieve better and faster recovery.
Moreover, helping patients overcome difficulties and gather ben-
efits from stressful experiences should be one of the main objec-
tives of clinical practitioners. In this regard, and given the
omnipresent nature of stress and stressors, it is important to
gather results from several studies to review current knowledge
on the efficacy of PP interventions against stress, anxiety, and
PTSD outcomes.
To examine the potential effects of PP interventions as an
intervention to stress‐related difficulties, we reviewed studies that
assessed the efficacy of these interventions in adult patients. We
identified studies from different databases and literature sources
that reported positive interventions aiming to reduce stress, anxiety,
and/or PTSD symptoms as an outcome in populations experiencing
different stressors. We examined interventions in terms of treatment
duration, their effects, and the resource on which they were based.
This review discusses results with regard to their public health and
clinical implications and suggests future directions for research.
ET AL.
2 | METHODS
2.1 | Eligibility criteria
&
We established several eligibility criteria. Research fields were
limited to published clinical trials studying the effects of PP‐based
interventions on stress, anxiety, or PTSD symptoms. Language was
restricted to English, Spanish, and French. There was no publication
date limitation. Adult participants of any age were included. Studies
that proposed positive psychotherapy or well‐known positive in-
terventions were included. We then decided to include derivatives of
positive dimensions (for instance, compassion‐based interventions).
Stress, anxiety, or posttraumatic stress symptoms (PTSS) had to be an
outcome for the study to be included.
2.2 | Research strategy
We identified studies by searching electronic databases and consul-
ting literature reviews and academic books. We searched PubMed,
Scopus, PsychINFO, Wiley, Sage, and Cochrane databases up to June
2021. In addition, we searched studies in several positive psychology
academic books.
We searched databases with the following keywords: positive
intervention; positive psychotherapy; stress, anxiety, post‐traumatic
stress; result; results; outcome; outcomes; effect*; efficacy. The key-
words were set to be searched in title and abstract whenever possible.
2.3 | Study selection and data extraction
S. Ferrandez evaluated articles unblinded for eligibility by reading the
title and abstract of the records and then screened them according to
the eligibility criteria. All authors then read the records that matched
the criteria or records that needed more information to be included
in their entirety. S. Ferrandez extracted and checked the data using
an original form inspired by several systematic reviews. The final data
extraction form includes the experimental design, the effect size for
stress/anxiety/PTSS outcomes, the dropout rate, the size of the
sample with men/women ratio, the type of participants included, the
type of intervention, a description of the control condition (when
possible), the length of the intervention, the measures used to eval-
uate the potential effects, and the authors' conclusion.
2.4 | Risk of bias assessment
To evaluate the risk of bias of individual studies, S. Ferrandez and L.
Vankenhove independently assessed the reliability of each study. Risk
of bias was assessed with the NIH study quality assessment tools
(National Institutes of Health, 2014a). Two tools were used: for
controlled trials, the Quality assessment of controlled intervention
studies (National Institutes of Health, 2014b) was used. For studies
FERRANDEZ ET AL.
with a pre‐post design, the quality assessment tool for before after
(pre‐post) studies with no control group (National Institutes of
Health, 2014a) was used. Each assessor assessed every study and rated
them with one of the following ratings: ‘good’, ‘fair’, or ‘poor’. A ‘good’
rating generally means that a study has a low risk of bias, with reliable
results, a ‘fair’ grade means that the study has some bias, but the results
remain reliable while a ‘poor’ rating means that the study has a high risk
of bias, and the results should not be considered sufficiently reliable.
After assessment, both assessors compared their results and
discussed until they were in full agreement.
3 | RESULTS
3.1 | Study selection
Figure 1 shows the study selection process. We first retrieved 954
records from database searches and 12 additional records from other
sources. Then, we removed 131 duplicates, so we screened 835 re-
cords for eligibility. From this step, we excluded 788 records because
they did not match eligibility criteria. Finally, we assessed 47 records
for eligibility by reading the full text. As a result, we excluded 18
records: Two were unavailable in English, Spanish, or French, one did
not correspond to our methodological design eligibility criteria, one
did not provided sufficient details for its intervention, two recruited a
child or an adolescent sample, four were not a positive intervention/
psychotherapy, seven did not assess stress, anxiety, or PTSS and one
article was unavailable in full text and the author did not respond to
our solicitations.
Out of the 29 included records, 19 were included from database
searches, and 10 were from other sources: seven were from previous
reviewing work and three were from included articles.
3.2 | Study characteristics
The studies varied regarding experimental designs. Six used a pre‐
post design with no control group, four were non‐randomized
controlled trials and 19 were randomized controlled trials. Among
studies including a control arm, 13 studies used an active control
group (meaning participants received some form of intervention)
while 10 used a delayed treatment/waitlist type of control group.
Studies recruited a broad range of participants. Six recruited war
veterans, four older adults, four recruited college students, three
recruited physically ill people, three recruited cancer survivors, two
recruited people with mental health problems, two recruited mothers
of infants, one recruited healthy adults without specification, one
recruited bereaved adults, one recruited spousal abuse victims, one
recruited teachers and one recruited unemployed people. Trials
recruited between 20 and 646 participants, although most recruited
medium or large samples (N > 60).
Most (21) studies used a group intervention, eight chose to use
an individual intervention. While every study aimed to train or
- 3
improve positive resources, they diverged regarding the improved
dimension. Six studies tried positive psychotherapy, five tried a mix of
positive interventions (such as the Three Good Things intervention,
the gratitude letter, and the best possible self), three tried a self‐
compassion intervention, three tried a spirituality‐based interven-
tion, two tried a meditation‐based intervention, two tried well‐being
classes, one tried strengths‐based intervention, one tried a positive
recollection intervention, one a mental time travel intervention, one
tried a post‐traumatic growth intervention, one tried a resilience skill
building class, one tried forgiveness therapy, one tried a positive
relationships intervention and one compared gratitude training,
savouring training and optimism training.
Anxiety was the primary outcome for 16 studies
(3,4,5,6,12,13,16,19,21,22,23,26,28,29)
and the secondary outcome for three
studies (2,10,24)
. PTSS symptoms were the primary outcome for 10
(1,2,8,9,12,13,14,17,18,22)
studies and the secondary outcome in three
(7,11,25) (4,12,15,20,27)
studies . Five studies had perceived stress as the
primary outcome and none as a secondary outcome. Multiple studies
did not specify whether an outcome was primary or secondary, so
unspecified outcomes were considered primary in this synthesis.
Measures for anxiety diverged among studies. Studies used the
Overall Anxiety Severity and Impairment Scale (Campbell‐Sills
et al., 2009), the State Trait Anxiety Inventory (Spielberger et al., 1983),
Hospital Anxiety Depression Scale (Zigmond & Snaith, 1983),
Depression Anxiety Stress Scale‐21 (DASS‐21, Lovibond & Lovi-
bond, 1995), Kellner symptom questionnaire (Kellner, 1987), a modi-
fied version of the Test Anxiety Inventory (Spielberger, 1980),
Liebowitz Social Anxiety Scale (Liebowitz, 1987), Generalized Anxiety
Disorder Scale (Spitzer et al., 2006), Goldberg Anxiety and Depression
Scale (Goldberg et al., 1988), The Symptom Checklist‐90 Revised
(Derogatis & Melisaratos, 1983). Most studies used subscales from
general mental difficulties questionnaires to assess anxiety.
The main tools used to assess PTSD symptoms were the
Clinician‐Administered PTSD Scale in its original (Blake et al., 1990)
and the Diagnostic and Statistical Manual of Mental Disorders (4th
ed.; DSM‐IV) version (Blake et al., 1998), the PTSD Checklist (Blan-
chard et al., 1996) in its original version, as well as the civilian version
and its updated version based on DSM‐5 (Blevins et al., 2015). The
PTSS Checklist from the DSM‐IV (American Psychiatric Associa-
tion, 1994) was also used to assess posttraumatic symptoms, as well
as the PTSD Symptoms Scale Interview (Foa et al., 1993) and the
Impact of Events Scale ‐Revised (Weiss, 2007).
Fewer tools were used to assess perceived stress, that is the
DASS‐21 (Lovibond & Lovibond, 1995), and the Perceived Stress
Scale (Cohen et al., 1983).
3.3 | Synthesis of the results
Table 1 provides information and details about the results of each
individual study. These results highlighted that positive interventions
seem to reduce stress, anxiety, and posttraumatic stress symptoms.
However, several studies reported a nonsignificant difference
4
- FERRANDEZ ET AL.

FIGURE 1 PRISMA flux diagram for the inclusion process

(2,8,15,21,22)
between the positive intervention and the control group. This could studies had a less than 10% dropout rate, six (1,10,13,17,18,20)
(4,5,6,11,28)
mean that while there is an effect of positive interventions, it is not had a dropout rate between 10% and 20%, five had a
(7,9,12,25)
better than treatments that are already offered. dropout rate between 21% and 30%, four had a dropout rate
(14,27,29)
Effect sizes for anxiety ranged from small to large. Four studies between 31% and 40%, 3 had a dropout rate between 41%
(3,21,22,28) (4,5,6,17) (24) (3,16,19,23,26)
reported a large effect size , four reported a mod- and 50% and one had a dropout rate over 50%. Five
(29)
erate effect size, 1 reported a small‐to‐moderate effect size, one articles did not provide sufficient details to assess the dropout rate.
(10) (26,12,2)
reported a small effect size, three reported non‐existent
(13,16,19,23,24)
effects and five reported a significant effect but did
not provide effect sizes for this outcome. 3.4 | Risk of bias in individual studies
Effect sizes for stress ranged from small to moderate. Three
(4,20,27)
records reported a moderate effect size, and one (15) reported Table 2 summarizes the risk for bias of each study. As previously
a small effect size. mentioned, S. Ferrandez & L. Vankenhove independently assessed
(9,11)
Effects sizes for PTSD ranged from small to large. Two re- risk of bias. Ten (34%) studies were graded ‘poor’, 12 (41%) studies
(1,2,12,14,18)
ported a large effect size, five reported a small effect size, were graded ‘fair’ and seven (24%) studies were graded ‘good’. Every
(7,8,25) (17)
three reported a moderate effect size, one reported a ‘poor’ grade was attributed because of a lack of reporting method-
(13,22)
moderate‐to‐large effect size, two reported a significant effect ological aspects. Percentages are rounded down, so the sum may not
but did not provide effect sizes for this outcome. add up to 100%.
Dropout rates were an outcome in few studies. However, most
articles provided sufficient information in the article to the calculate
dropout. As the studies varied in length, dropout rates were calcu- 4 | DISCUSSION
lated from allocation (starting point) to intervention completion
(ending point), so patients lost before the beginning of the interven- To our knowledge, this is the first review of positive interventions as
tion or lost to follow‐up were not considered as dropouts. Six a treatment for stress, anxiety and PTSD. The review shows that
TABLE 1 Summary of the included studies

Sample
Control Intervention
FERRANDEZ

No Study N M/F ratioa Population‐type Intervention name group length Measures Results

1 Bormann 33 100/0 War Spiritually Delayed Six PCL CAPS Intervention group reported
ET AL.

et al. (2008) veterans based treatment weekly 90‐min BSI‐18 greater improvements in PTSS
group group (d = −0.33 and −0.72),
intervention sessions psychological distress
(d = −0.73), and spiritual well‐
being (d = 0.67) versus control
group.

2 Bormann 136 97/3 War veterans Meditation‐based TAU Six 90‐min weekly group CAPS PCL‐C Intervention group reported lower
et al. (2013) mantram sessions BSI‐18 PTSS (η2p = 0.03) and higher
intervention + TAU well‐being (η2p = 0.14) scores
than control but no difference
in anxiety.

3 Dambrun 21 47/53 Unemployed Altruism, gratitude, TAU Two 30‐min STAI Intervention
and people strengths and weekly sessions group
Dubuy (2014) optimism training reported lower
state (η2 = 0.38)
and trait
anxiety
(η2 = 0.19)

4 Duan and 52 42/58 Undergraduate Single‐session Waitlist One 90‐min lesson BIT DASS‐21 Intervention group reported
Bu (2019) students character‐strength‐ SKS SUS higher thriving (η2p = 0.07),
based cognitive strength knowledge (d = 0.49),
intervention strength use (d = 0.76), lower
anxiety (η2p = 0.11) and stress
(η2p = 0.11).

5 Friedman 103 14/86 Older Lighten UP! No control Eight 90‐min PWB Kellner Improvement in psychological
et al. (2017) adults a community‐based group classes symptom well‐being (η2p = 0.12)
group questionnaire and anxiety (η2p = 0.11).
intervention

6 Friedman 217 15/85 Older adults Lighten UP! a No control group Eight 90‐min classes PWB Kellner Improvement in psychological
et al. (2019) community‐based symptom well‐being (η2p = 0.05), and
group intervention questionnaire anxiety (η2p = 0.06).

7 Grodin 22 96/4 War veterans Compassion focused No control group 1–12 group sessions PCL‐5 Improvement in PTSS (d = −0.53)
et al. (2019) therapy for anger

8 Harris 54 74/26 War veterans BSS Waitlist Eight group sessions lasting PCL The BSS group reported a greater
et al. (2011) 2 h each reduction in PTSS (d = −0.67).

9 Harris 138 76/24 War BSS Present‐centred Eight group CAPS‐IV PCL‐C Both groups reported a significant
et al. (2018) veterans group therapy sessions lasting reduction in CAPS scores
-

(Continues)
5
 6

T A B L E 1 (Continued)
-

Sample
Control Intervention
No Study N M/F ratioa Population‐type Intervention name group length Measures Results

2 h each (d = −1.06 pre‐to‐post BSS),

but did not report a significant
reduction in PCL‐C.

10 Huffman 26 Not Patients with Gratitude, optimism, Active control: Eight weekly individual HADS SHS Positive intervention group
et al. (2011) communicated acute altruism and relaxation sessions reported lower anxiety
cardiovascular choice‐based response symptoms than both control
disease intervention groups (d = −0.19 pre‐to‐post
Attentional control:
intervention) and higher
recollection of
subjective happiness (d = 0.68
life events
pre‐to‐post intervention) than
attentional control but not
active control

11 Kearney 42 58/42 War veterans Loving‐kindness No control group Twelve 1.5‐hour group PSS‐I PROMIS Improvement in PTSS (d = −0.89)
et al. (2013) meditation for meditation classes SCS
Improvement in self‐compassion
PTSD
(d = 0.79)

Self‐compassion mediated PTSD

improvements

12 Lennard 646 0/100 Mothers of infants Online self‐compassion Waitlist Eight weeks individual DASS‐21 IES‐R Intervention group reported lower
et al. (2021) intervention access to online PTSS (η2p = 0.015), but not for
resources stress or anxiety

13 Lleras de 269 0/100 Cancer Online positive Face‐to‐face Eleven weekly HADS PCL‐C Both groups reported lower
Frutos et al. survivors psychotherapy positive online group PTGI anxiety
(2020) for distressed psychotherapy sessions of and PTSS. Face‐to‐face
cancer survivors 90 to 120 positive
min + 1 psychotherapy group reported
face‐to‐face higher PTG
90 session

14 Mitchell 262 0/100 Mothers of infants Online self‐compassion No control group One month individual IES‐R Lower PTSS at post‐intervention
et al. (2018) intervention access to online (d = −0.11)
resources

15 Mohamadi 76 Patients with PPT, MBCT Waitlist Eight‐week PSS Intervention groups reported
et al. (2019) irritable bowel and DBT 2.5 h group lower perceived stress
syndrome therapy (d = 0.21).
sessions

16 Nelson and 118 35/65 College Positive recollection Write about One‐time Test anxiety Intervention group reported less
Knight (2010) students of memories morning exercise inventory test anxiety
routines
FERRANDEZ
ET AL.
T A B L E 1 (Continued)

Sample
Control Intervention
FERRANDEZ

No Study N M/F ratioa Population‐type Intervention name group length Measures Results

17 Ochoa 158 0/100 Cancer survivors Positive psychotherapy Waitlist Twelve weekly group PCL‐C HADS Intervention group reported lower
ET AL.

et al. (2017) sessions of 90–120 min PTGI PTSS (η2p = 0.09 to 0.17),
anxiety (η2p = 0.12), and
higher PTG.

18 Ochoa‐Arnedo 140 0/100 Cancer survivors Positive psychotherapy Stress reduction Twelve weekly group PCL‐C HADS Intervention group reported lower
et al. (2020) intervention sessions of 90–120 min PTGI PTSS (d = −0.32 at post‐
intervention, d = −0.26 at 12
months), distress (d = −0.14 at
post intervention, d = −0.84 at
12 months) but not higher
PTG.

19 Quoidbach 210 35/65 Healthy adults Mental time travel into No intervention Fourteen daily exercises STAI SHS The positive projection group
et al. (2009) a positive/neutral/ reported higher happiness,
negative future neutral projection group
reported lower anxiety.

20 Rahm and 89 26/74 Teachers Emotion diary, Waitlist One group training day + 2 PSS BIT SLWS Less perceived stress (d = −0.49)
Heise (2019) gratitude and booster sessions over more flourishing (d = 0.43) and
happiness training 5 weeks more life satisfaction
(d = 0.40)

21 Ramírez 56 37/63 Older adults A memories, gratitude Placebo Nine 1.5‐hour weekly group STAI LSS SHS Intervention group reported lower
et al. (2014) and forgiveness interventions sessions state anxiety (η2p = 0.21),
program higher life satisfaction
(η2p = 0.10) and higher
happiness (η2p = 0.09)

22 Reed and 20 0/100 Spousal Forgiveness Anger validation, Eight months STAI PTSS Forgiveness therapy showed
Enright psychological therapy assertiveness, of 1‐hour better improvements in the
(2006) abuse victims interpersonal individual number of PTSS, and less trait
skill building weekly anxiety (d = −0.89)
sessions
(average)

23 Rivera 56 20/80 Patients with Social and emotional No control group Eleven 30‐min individual STAI LSAS Less state, trait and social anxiety
et al. (2015) myasthenia skills weekly sessions after the interventions

24 Roepke 283 30/70 Patients with On‐app PPT / on‐app Waitlist At least 10‐min daily for GAD‐7 SWLS Intervention groups reported
et al. (2015) depression PPT + CBT 1 month lower anxiety and higher well‐
being than control group

25 Roepke 112 36/64 Bereaved adults SecondStory, a Narrative writing One 6‐hour‐long group PTGI PCL‐C Both groups improved in PTG
et al. (2018) posttraumatic‐ session + one optional SWLS (d = 0.33 and 0.14). Both
(Continues)
-
7
 8

T A B L E 1 (Continued)
-

Sample
Control Intervention
No Study N M/F ratioa Population‐type Intervention name group length Measures Results

growth‐focused 1‐hour‐long group groups reported reduced PTSS

intervention session (within group d = 0.65
(SecondStory) and d = 0.04
between groups) and
unchanged satisfaction with
life.

26 Salces‐Cubero 124 41/59 Older Gratitude, Waitlist Four 70‐min GADS SLWS SHS Gratitude and savouring training
et al. adults optimism or group sessions Resilience groups reported higher life
(2019) savouring scale satisfaction (η2p = 0.22),
training happiness (η2p = 0.08),
resilience (η2p = 0.16) but no
difference in anxiety

27 Shatkin 98 11/89 College Resilience Child and Two semester‐ PSS Resilience skill building course
et al. students skill adolescent long brief COPE group reported lower stress
(2016) building psychopathology course (g = 0.74) and higher coping
course course skills (g = 0.50)

28 Taylor 29 45/55 Adults with Positive activity Waitlist Ten 1‐hour OASIS STAI Intervention group reported lower
et al. (2017) anxiety and/or intervention individual SWLS STAI anxiety (d = 0.94) and higher
depression sessions trait psychological well‐being
(d = 1.57) than control group

29 Uliaszek 54 22/78 Treatment‐ Positive psychotherapy Dialectical behaviour Twelve‐weeks group SCL‐90R SWLS DBT group (d = 0.61) reported
et al. (2016) seeking college therapy therapy lower anxiety than PPT
students (d = 0.44). DBT group reported
higher life satisfaction than
PPT

Abbreviations: η2p, partial eta squared; BIT, brief inventory of thriving; BSI‐18, brief symptom inventory‐18; BSS, building spiritual strength; CAPS, clinician‐administered PTSD scale; DASS‐21, depression
anxiety stress scale‐21; d, Cohen's d for effect sizes; DBT, dialectical behaviour therapy; depression anxiety stress scales short form; g, Hedge's g for effect sizes, GAD‐7, generalized anxiety disorder scale;
GADS, Goldberg anxiety and depression scale; HADS, hospital anxiety and depression scale; IES‐R, impact of event scale–revised; LSAS, Liebowitz social anxiety scale; OASIS, overall anxiety severity and
impairment scale; PCL, posttraumatic stress disorder checklist; PCL‐5, posttraumatic stress disorder checklist; PCL‐C, posttraumatic stress disorder checklist civilian version; PHQ‐9, patient health
questionnaire 9 items; PPT, positive psychotherapy; PROMIS, patient‐reported outcomes measurement information system; PSS, perceived stress scale; PSS‐I, PTSD symptom scale‐interview; PTGI,
posttraumatic growth inventory; PTSS‐checklist, posttraumatic symptoms checklist; PWB, Ryff psychological well‐being scale; SCL‐90R, symptom checklist‐90 revised; SCS, self‐compassion scale; SHS,
subjective happiness scale; SKS, strength knowledge scale; STAI, state trait anxiety inventory; STAXI‐2, state‐trait anger expression inventory‐2; SUS, strength use scale; SWLS, satisfaction with life scale;
TAU, treatment as usual.
a
Male/female ratio in percentage.
FERRANDEZ
ET AL.
FERRANDEZ ET AL.
- 9

T A B L E 2 Estimated risk of bias of

Study Study design Risk of bias
individual studies
Bormann et al. (2008) RCT Fair

Bormann et al. (2013) RCT Good

Dambrun and Dubuy (2014) Nonrandomized controlled trial Poor

Duan and Bu (2019) RCT Fair

Friedman et al. (2017) Before‐after study with no control group Fair

Friedman et al. (2019) Before‐after study with no control group Good

Grodin et al. (2019) Before‐after study with no control group Fair

Harris et al. (2011) RCT Poor

Harris et al. (2018) RCT Fair

Huffman et al. (2011) RCT Poor

Kearney et al. (2013) Before‐after study with no control group Fair

Lennard et al. (2021) RCT Fair

Lleras de frutos et al. (2020) RCT Fair

Mitchell et al. (2018) Before‐after study with no control group Good

Mohamadi et al. (2019) RCT Poor

Nelson and Knight (2010) RCT Poor

Ochoa et al. (2017) Nonrandomized controlled trial Good

Ochoa‐arnedo et al. (2020) RCT Good

Quoidbach et al. (2009) RCT Poor

Rahm and Heise (2019) Nonrandomized controlled trial Fair

Ramírez et al. (2014) RCT Poor

Reed and Enright (2006) RCT Poor

Rivera et al. (2015) Before‐after study with no control group Good

Roepke et al. (2015) RCT Fair

Roepke et al. (2018) RCT Good

Salces‐cubero et al. (2019) RCT Poor

Shatkin et al. (2016) Nonrandomized controlled trial Poor

Taylor et al. (2017) RCT Fair

Uliaszek et al. (2016) RCT Fair

nearly all 29 studies demonstrated an improvement in stress‐related
symptoms, yet some did not show better results compared with the
control group. The studies tended to demonstrate significant results
on other outcomes like hedonic well‐being or happiness. This review
shows that while the interventions varied greatly, they promoted
similar effects. The results from the review appear to indicate that
positive interventions can help reduce perceived stress, anxiety, and
PTSS.
One of the possible mechanisms of action of these interventions
is that developing positive resources contributes to reducing stress‐
related symptoms. This phenomenon is consistent with existing
literature on protective factors of stress, anxiety, and PTSD (Mednick
et al., 2007; Nateghian et al., 2015; Wood et al., 2008). These positive
skills could be resilience factors for patients. In this case, the ability
to develop internal resources to overcome adversity and psycho-
logical stress for people at risk of developing psychopathologies
seems to be a promising lead for novel therapeutic or preventive
approaches. This outcome implies that positive interventions could
be used both as a prevention tool and as a therapeutic trans-
diagnostic intervention. There is some evidence that positive pre-
ventions can be useful in the prevention of pathologies such as eating
disorders (Steck et al., 2003).
Regarding dropout rates, there seems to be no difference be-
tween PP interventions and treatment as usual. Studies that
compared dropout rates did not report significant differences with
control groups. However, there was a high variability between
studies regarding dropouts, preventing us from drawing reliable
conclusions in this area.
10
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This review has several limitations. While there is a vast array of
interventions, only a few were tested as a treatment for stress,
anxiety, or PTSD specifically. A high number of studies included
measures of stress‐related symptoms by using composite measures
of psychological distress or had stress, anxiety, or PTSD as secondary
outcomes. Given that we screened studies based on their title and
abstract, it is possible that we omitted studies because they did not
describe their intervention as ‘positive’ in that information. Another
potential risk of bias is that systematic reviews are subject to the file
drawer problem (Rosenthal, 1979), which is a publication bias that
considers statistically significant studies are largely overrepresented
in scientific literature. Thus, systematic reviews screen articles from
biased databases. Further research should also investigate grey
literature to avoid publication biases.
Moreover, there were crucial methodological design variations
among the studies. While most studies opted for a randomized
controlled design, studies used many different assessment tools, with
varying methods of randomization and various types of control
conditions. The risk of bias of the individual studies also weakens the
level of evidence. There are disparities in the level of reporting that
should be questioned. This review included 29 studies that tried 21
different interventions. This finding implies that one cannot gener-
alize the effects of one intervention to another. Given the hetero-
geneity of studies, the differences of included participants and, more
importantly, the great diversity in the interventions, these results
should be viewed with caution. Despite those limitations, positive
interventions seem to show promise as a possible intervention for
stress‐related difficulties. However, the low level of evidence means
that clinical practitioners should remain cautious. Several well‐
established transdiagnostic treatments are available for stress, anx-
iety, or PTSS, such as the Unified Protocol for Emotional disorders
(Sakiris & Berle, 2019) or Mindfulness Stress Reduction Programs
(Chiesa & Serretti, 2009) and these should be considered as the
current best‐practice options.
Positive psychology aims to promote health by the development
of well‐being, strengths, and resources (Seligman, 2008). These in-
terventions, along with other positive interventions, seem to improve
resources such as self‐compassion or finding meaning skills. They also
seem to bear good acceptability, which could be useful as a com-
plementary approach to more deficit‐focused psychotherapeutic
approaches. In addition, using PP interventions as a supplement to
treatment as usual could achieve better results because they seem to
use different mechanisms of action. Integrative approaches like these
should be tested to ascertain their safety and efficacy.
More randomized controlled trials with similar methodology and
comparable interventions are needed to establish a higher level of
evidence. While this review included studies conducted on very
different populations, none tried to apply the same method on
different samples. This could be relevant to investigating whether
different stressors would result in variable outcomes.
CO N F LI C T O F I N T ER ES T
The authors have declared that they have no conflict of interest.
ET AL.
D A T A A V A I LA B I L I T Y S T A T E M E N T
The detailed research strategy of this study are available from the
corresponding author upon reasonable request.
ORCID
Sébastien Ferrandez https://orcid.org/0000-0002-0442-7779
Andrea Soubelet https://orcid.org/0000-0002-9263-4785
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How to cite this article: Ferrandez, S., Soubelet, A., &
Vankenhove, L. (2021). Positive interventions for stress‐
related difficulties: A systematic review of randomized and
non‐randomized trials. Stress and Health, 1–12. https://doi.
org/10.1002/smi.3096