2

 Clinically, a positive-memory intervention may contribute to reduced PTSD severity.

 Empirical investigations on positive-memory intervention effects for PTSD are needed.

Abstract

PT
Encoding and retrieval difficulties, and avoidance of both traumatic and positive

RI
memories, are associated with posttraumatic stress disorder (PTSD) symptoms. However, most

SC
PTSD research and clinical work has solely examined the role of traumatic memories in the

maintenance/resolution of PTSD symptoms. Our current review provides a comprehensive

U
discussion of the literature on positive memories and PTSD. First, we review theories and

N
empirical evidence on the relations between trauma, PTSD, and memory processes (particularly
A
positive memories). Next, we propose a conceptual model that integrates empirical evidence
M

from experimental and positive/memory-based intervention research and highlights hypothesized

mechanisms underlying the potential effectiveness of targeting positive memories in PTSD

D

interventions. Specifically, we discuss how targeting positive memories could (1) increase
TE

positive affect and reduce negative affect, (2) correct negative cognitions, (3) increase specificity
EP

of retrieving autobiographical memories, and (4) be effectively integrated/sequenced with and

enhance the effects of trauma-focused interventions. Lastly, we suggest clinical research avenues
CC

for investigating the relationship between positive memories and PTSD to possibly alter the

current PTSD intervention paradigm focused only on traumatic memories. Overall, our proposed
A

model drawing from experimental and intervention research and outlining potential effects of

targeting positive memories to reduce PTSD severity needs further empirical investigation.
 3

Keywords. Posttraumatic stress disorder; traumatic memories; positive memories; clinical

considerations.

1. Introduction

PT
Disrupted encoding, consolidation, and retrieval of emotional memories are implicated in

RI
the etiology, symptomatology, and treatment of posttraumatic stress disorder (PTSD; Brewin &

Holmes, 2003). Given that most research has examined traumatic memories in relation to PTSD

SC
symptoms (e.g., Bernsten & Rubin, 2007), most current PTSD interventions primarily target

traumatic memories (Schnurr, 2017). However, difficulties in the retrieval of (specific) positive

U
memories also relates to PTSD severity (McNally, Lasko, Macklin, & Pitman, 1995; Schönfeld
N
& Ehlers, 2017). Although emerging experimental research is beginning to examine the relations
A
between positive memories and PTSD symptoms, these findings have yet to be integrated into
M

clinical intervention research. Results from such intervention research can inform the possibility
D

of processing positive and traumatic memories as a part of PTSD interventions.

TE

As such, the current paper discusses theoretical underpinnings of and empirical evidence

for the relations between PTSD and traumatic/positive memories. Drawing on existing
EP

experimental and intervention research, we next propose a preliminary testable conceptual model
CC

(Figure 1) outlining hypothesized effects of targeting positive memories in PTSD interventions

to reduce PTSD severity such as enhanced positive affect and (more accurate) cognitions,
A

reduced negative affect, increase in autobiographical memory specificity (AMS), and

augmentation of trauma-focused intervention effects (increasing ease of processing specific

positive memories, increasing readiness to start trauma-focused interventions, reducing fear in

discussing traumatic memories, enhancing therapeutic alliance, increasing ease and effectiveness
 4

of processing traumatic memories, and decreasing drop-out rates). We then highlight areas in

need of future research, particularly those with clinical relevance.

2. PTSD and Memory Processes

PTSD’s diagnostic criteria include intrusive thoughts and memories about the trauma,

PT
avoidance of trauma reminders, negative alterations in cognitions and mood (NACM), and

alterations in arousal and reactivity (AAR) following the experience of a traumatic event

RI
(American Psychiatric Association, 2013). PTSD is consistently conceptualized as a memory

SC
encoding- and retrieval-based disorder, with memory process disruptions involved in the etiology

and/or maintenance of PTSD symptoms (Brewin, 2014; Ehlers & Clark, 2000; Foa, Zinbarg, &

U
Rothbaum, 1992; Rubin, Berntsen, & Bohni, 2008). As an example, Lang’s associative network

N
theory (1979) states a fear memory includes interconnected information about the original
A
traumatic event: 1) stimulus-related, 2) emotional and physiological reactions, and 3) meaning
M

attributed to the trauma. Trauma reminders may activate this fear memory and produce reactions

and meaning interpretations similar to those experienced during the trauma (reviewed in Brewin
D

& Holmes, 2003). Applying Lang's (1979) theory, Foa and colleagues (Foa & Kozak, 1986; Foa,
TE

Steketee, & Rothbaum, 1989) proposed the Emotional Processing Theory emphasizing that a
EP

trauma causes the formation of new associations between previously unrelated factors, such that

these trauma-related stimuli are then perceived as threatening. The activation of the fear network
CC

by trauma reminders causes threat-related information to enter consciousness (PTSD intrusion

symptoms) and attempts to suppress such activation categorize PTSD avoidance symptoms
A

(reviewed in Dalgleish, 2004). Further, Brewin et al.’s (2010) revised dual representation theory

of visual intrusions indicates that traumatic memories are stored in two representational formats:

a context-dependent and consciously accessible contextual memory (C-memory) and its

 5

representations (C-reps); and an emotional/autonomic response-oriented sensation-based

memory (S-memory) and its representations (S-reps). PTSD symptoms (e.g., flashbacks) relate

to the presence of strong S-reps in response to a stressful event, with avoidance hindering the

integration of weaker C-reps with the corresponding S-reps (Brewin et al., 2010).

PT
Although most trauma theories highlight the importance of understanding different types

of memories among individuals with PTSD symptoms (Brewin, 2014; Ehlers & Clark, 2000; Foa

RI
& Kozak, 1986; Foa et al., 1992; Horowitz, 1986; Rubin et al., 2008), several PTSD

SC
interventions primarily target the understanding and processing of primarily traumatic memories

(Cusack et al., 2016; Schnurr, 2017). Further, the distinction in limited empirical research is

U
usually made between traumatic and “non-traumatic memories,” collapsing positive memories

N
with neutral memories in the category of “non-traumatic memories.” Consequently, there is less
A
emphasis on understanding the unique relationship between traumatic events, PTSD symptoms,
M

and positive memories (Lyubomirsky, Sousa, & Dickerhoof, 2006), and subsequently little

consideration of whether targeting positive memories could ameliorate PTSD symptoms.

D

3. PTSD and Positive Memories

TE

Positive memories are defined as memories of salient and personally meaningful positive
EP

experiences with highly favorable connotations and consequences (Bernsten, 2001); such

memories have shorter retrieval times (Lishman, 1974) and may function as personal reference
CC

points to influence the interpretation of other experiences and personal identity (Bohanek,

Fivush, & Walker, 2005; Pillemer, 1998; Rubin & Kozin, 1984). There may be a bi-directional
A

relationship between positive memories (and related processes) with PTSD symptoms. First,

positive memory-related processes and characteristics as pre-trauma risk factors may contribute

to the etiology of PTSD following trauma. Examples include fewer salient pre-trauma positive
 6

experiences/memories (Hauer, Wessel, Engelhard, Peeters, & Dalgleish, 2009), genetic factors

contributing to decreased encoding of positive memories (Dominique et al., 2012), difficulties

accessing pre-trauma positive memories (Bryant, Sutherland, & Guthrie, 2007), and lack of a

pre-trauma secure positive self-concept (Bryant & Guthrie, 2007; Foa & Rothbaum, 2001;

PT
Janoff-Bulman, 1992). Such pre-trauma risk factors may be appropriate targets for prevention-

oriented clinical work and for remedial clinical interventions using positive reappraisal and

RI
reframing techniques (Foa & Rothbaum, 2001; Janoff-Bulman, 1992).

SC
Second, positive memory-related processes and characteristics as post-trauma risk factors

may contribute to the maintenance of PTSD severity following trauma. The salience of traumatic

U
memories and associated negative cognitions/feelings among trauma-exposed individuals may

N
inhibit the retrieval of positive memories and associated positive cognitions/feelings (Brewin,
A
Dalgleish, & Joseph, 1996; Brewin et al., 2010; Brewin & Holmes, 2003). Further, trauma-
M

exposed individuals may also experience difficulties in the retention of positive memories (Porter

& Peace, 2007) and/or integration of positive memories with other autobiographical memories
D

(Bernsten & Rubin, 2007; Berntsen & Rubin, 2006). In addition, formation of new positive
TE

memories among trauma-exposed individuals may be impaired through several processes: failure
EP

to recognize positive life events and/or interpret events in a positive light (Kangas, Henry, &

Bryant, 2005; Paunovic, Lundh, & Öst, 2002), reduced ability to process rewards or lower
CC

expectancy for rewards (Elman et al., 2005; Hopper et al., 2008), co-occurring distressing

emotions (Werner-Seidler & Moulds, 2011), co-occurring maladaptive cognitions (Sutherland &
A

Bryant, 2007), and co-occurring ineffective behaviors (Littleton, Horsley, John, & Nelson,

2007). Such retrieval, integration, and consolidation failures for positive memories may

contribute to greater PTSD severity in the long-run (Brewin & Holmes, 2003).
 7

Existing evidence indicates difficulties accessing and reporting non-traumatic memories

(de Decker, Hermans, Raes, & Eelen, 2003; Hayes, VanElzakker, & Shin, 2012; Schönfeld &

Ehlers, 2017), in particular positive (Bryant et al., 2007; Nixon, Ball, Sterk, Best, & Beatty,

2013; Sutherland & Bryant, 2008a) and specific memories (limited to a certain time frame with

PT
specific information; McNally et al., 1995; McNally, Litz, Prassas, Shin, & Weathers, 1994)

among trauma-exposed individuals. Potential explanations for these deficits include attentional

RI
biases towards negative information (Aupperle, Melrose, Stein, & Paulus, 2012; Fani et al.,

SC
2012; McNally et al., 1995), rumination on negative memories prompted by trauma reminders

(Ehlers & Clark, 2000), and numbing/emotion dysregulation symptoms (e.g., inability to

U
experience/regulate positive affect, inability to regulate negative affect, anhedonia; Litz, Orsillo,

N
Kaloupek, & Weathers, 2000; Weiss, Dixon-Gordon, Peasant, & Sullivan, in press). Further,
A
reduced AMS (difficulties retrieving specific memories; de Decker et al., 2003; Hayes et al.,
M

2012; McNally et al., 1994) may be a cognitive strategy to avoid accessing any memories

triggering uncomfortable emotions (Dalgleish, Rolfe, Golden, Dunn, & Barnard, 2008). Over
D

time, trauma-exposed individuals may avoid thinking about negative and positive memories
TE

because of worries that thinking about the past may trigger trauma-related thoughts and feelings.
EP

From a clinical intervention perspective, the avoidance of and difficulty retrieving both

traumatic and positive memories prevents (1) the integration of traumatic memories into
CC

autobiographical memories and (2) the possible benefits of activating positive memories in

reducing PTSD severity (Megías, Ryan, Vaquero, & Frese, 2007). Additionally, clinicians do not
A

link targeting positive memories to alleviation of distress (Lyubomirsky et al., 2006) and discuss

traumatic (versus positive) experiences more frequently (Byrne, Hyman, & Scott, 2001). Overall,

the potential effects of focusing on positive memories has been relatively unexplored and
 8

research in this area may offer new clinical routes for reducing PTSD severity; we next discuss

relevant literature to this end.

4. Potential Effects of Targeting Positive Memories in PTSD Interventions

To highlight the clinical relevance of targeting positive memories in PTSD interventions,

PT
we propose a conceptual model integrating findings from experimental and intervention research

(see Figure 1). First, our proposed model draws from well-supported experimental (primarily

RI
cognitive psychology) research indicating the effects of (1) positive memories on affect and

SC
cognitive change (Bryant, Smart, & King, 2005; Josephson, 1996; Rusting & DeHart, 2000), and

(2) specific positive memory retrieval on reduced mental health symptoms (Neshat-Doost et al.,

U
2013) and reparation of negative affect (Hall, De Raedt, Timpano, & Joormann, 2018).

N
Second, our proposed model draws from effective positive interventions inherent to
A
positive psychology (Sin & Lyubomirsky, 2009), which aim to increase positive therapeutic
M

outcomes by promoting positive thoughts, feelings, and behaviors, rather than by decreasing

negative factors (Parks & Biswas-Diener, 2013). Components of positive interventions most
D

relevant to our model include: writing about a peak positive experience (Burton & King, 2004),
TE

sharing positive narratives with a partner (Lambert et al., 2013), using positive mental imagery to
EP

experience physiological and psychological ease (Watanabe et al., 2006), re-experiencing

pleasant memories using mental imagery (Bryant et al., 2005), and using prompts to talk about
CC

earlier positive memories (Pinquart & Forstmeier, 2012). Relatedly, our proposed model also

draws from the Broad-Minded Affective Coping (BMAC) intervention, which is a positive
A

emotion induction technique via recall of positive autobiographical memories (Tarrier, 2010).

BMAC has been linked to increased positive and reduced negative emotions among individuals

with PTSD (Panagioti, Gooding, & Tarrier, 2012). In this manner, our model’s clinical relevance
 9

is enhanced by drawing from interventions promoting resourcefulness and coping skills (Jané-

Llopis & Barry, 2005) to support sustainable change (Barry, 2007).

Lastly, our proposed model draws from effective interventions capitalizing on increasing

memory retrieval to improve mental health outcomes. As an example, MEmory Specificity

PT
Training (MEST), which focuses on increasing retrieval of specific memories (i.e., enhanced

AMS; Raes, Williams, & Hermans, 2009), has been associated with reduced PTSD severity

RI
among Iranian combat Veterans with PTSD (Moradi et al., 2014) and reduced depression

SC
severity among trauma-exposed adolescents (Neshat-Doost et al., 2013). A recent experimental

study examining Positive Memory Enhancement Training (PMET), an intervention that

U
promotes mood regulation among individuals with depression, found that participants who

N
received training in recalling, imagining, and relieving a “happy” memory (PMET condition)
A
successfully repaired induced negative mood (Hall et al., 2018). Additionally, Competitive
M

Memory Training (COMET) among other techniques, involves the generation of positive stories

to strengthen positive views about oneself (Korrelboom, de Jong, Huijbrechts, & Daansen, 2009;
D

Korrelboom, Maarsingh, & Huijbrechts, 2012) and has been shown to improve self-esteem
TE

among individuals with eating disorders (Korrelboom et al., 2009), depression (Korrelboom et
EP

al., 2012), and personality disorders (Korrelboom, Marissen, & van Assendelft, 2011). A recent

clinical trial (pending results) examined a Positive Memory Training (PoMeT) protocol focused
CC

on the integration of imagery and self-statements to relive a positive memory and activation of

positive self-representations when a cue triggers negative self-representations for individuals

A

experiencing depression and schizophrenia symptoms (Steel et al., 2015).

Although research within this area is preliminary, components from experimental and

intervention research could inform the development of a positive-memory intervention for PTSD
 10

based on our proposed model. For this intervention, we envision clients would retrieve and

process positive memories, primarily by thinking about them, writing about them, and/or

discussing them in detail with a therapist. In replaying, reliving, rehearsing, and analyzing salient

and specific positive memories, clients may access and solidify/strengthen core positive values,

PT
affect, and thoughts (self, world, and future); and engage in subsequent positive affective (e.g.,

experiencing affection for family members), cognitive (e.g., reminding oneself of the value

RI
placed on enjoying activities), and behavioral (e.g., sharing with a family member activities they

SC
enjoyed in the past) changes (Quoidbach, Mikolajczak, & Gross, 2015). Identifying positive

values, affect, and thoughts may solidify such aspects to make them more integral to individuals’

U
identities (Hitlin, 2003; King, Hicks, Krull, & Del Gaiso, 2006).

N
Our proposed positive-memory intervention has some similarities and differences
A
compared to trauma-focused interventions (Schnurr, 2017) such as Prolonged Exposure (PE;
M

Foa, Hembree, & Rothbaum, 2007) and Cognitive Processing Therapy (CPT; Resick &

Schnicke, 1992). Although the targeted clinical outcome of reduced PTSD severity and the
D

procedure of processing a memory (e.g., narrating) in our proposed positive-memory

TE

intervention is similar to that of trauma-focused interventions (Foa, 2011; Resick & Schnicke,
EP

1992; Sloan & Marx, 2017), our positive-memory intervention uniquely emphasizes detailed

access and enhancement of core positive elements and engagement in subsequent positive
CC

behavioral changes (Quoidbach et al., 2015) via processing of specific positive memories. At

times, PE (Foa et al., 2007) and CPT (Resick & Schnicke, 1992) may emphasize positive
A

elements although they are not central to the respective treatment protocols; example include the

incorporation of items involving exposure to potentially pleasurable experiences to promote

confrontation of trauma-related avoidance and retrieval of positive memories (and associated

 11

positive elements) corrective to the pathological fear structure in PE (Foa, 2011) and elicitation

of cognitions embedded in positive memories (e.g., experiences of trust) to facilitate cognitive

restructuring of maladaptive trauma-related beliefs in CPT (Resick & Schnicke, 1993). Uniquely,

our proposed positive-memory intervention targets an extensive and detailed processing of

PT
specific positive memories. Irrespective of whether the positive-memory intervention is used

sequentially or concurrently with trauma-focused work, it may increase access to clients’

RI
ignored/impaired positive beliefs and affect without requiring willingness to immediately engage

SC
in trauma-focused work, may subsequently facilitate willingness to transition to trauma-focused

work as individuals reconnect with a positive self, and may enhance effectiveness of PE

U
(providing incompatible information for fear structure) and CPT (providing content for cognitive

N
restructuring) for clients unwilling or unable to immediately pursue trauma-focused work.
A
Our proposed positive-memory intervention has some similarities and differences with
M

Behavioral Activation therapy as well. Similar to mechanisms underlying Behavioral Activation

(Dimaggio & Shahar, 2017), accessing and strengthening positive affect, thoughts, and values
D

while engaging in positive behavioral changes may be positively reinforcing and motivating to
TE

the client (e.g., source of pleasure, mastery, and satisfaction), and may increase their capacities to
EP

cope effectively. This is relevant given that Behavioral Activation has demonstrated utility

across a variety of trauma-exposed populations, including Veterans with PTSD (Jakupcak et al.,
CC

2006), Veterans with comorbid pain and PTSD (Plagge, Lu, Lovejoy, Karl, & Dobscha, 2013),

Veterans with PTSD and depression in primary care (Jakupcak, Wagner, Paulson, Varra, &
A

McFall, 2010), and combat Veterans with PTSD receiving telehealth services (Acierno et al.,

2016). Differing from Behavioral Activation, increased positive reinforcement and decreased

punishment are not conceptualized as the primary and sole mechanisms of change in our
 12

proposed intervention; rather we propose that focusing on positive memories will additionally

help regulate affect and modify rigid cognitions.

Overall, our proposed positive-memory intervention for PTSD could be conceptualized

as a hybrid of a positive and symptom-focused intervention, with an emphasis on increasing

PT
positive elements (values, affect, thoughts) while simultaneously decreasing PTSD severity. Our

proposed intervention focuses on reducing PTSD severity, specifically via three hypothesized

RI
pathways (see Figure 1). We elaborate on these mechanisms below.

SC
4.1. Path 1 Effects on PTSD Severity (Figure 1)

4.1.1. Increased Positive Affect and Decreased Negative Affect (PTSD NACM symptoms). We

U
propose that a focus on positive memory would directly impact symptoms of emotional numbing

N
and dysregulation present in PTSD, as further discussed below.
A
Theoretically, the role of emotional numbing/dysregulation symptoms in PTSD has been
M

widely discussed. Horowitz (1986) in his stress response theory suggested that trauma responses

are characterized by shock and information overload which causes individuals to use defense
D

mechanisms (e.g. numbing) to consciously avoid traumatic information. However, the need to
TE

integrate this new trauma-related information with existing knowledge keeps the trauma-related
EP

information in active memory resulting in PTSD intrusion symptoms. Thus, intrusion and

numbing symptoms oscillate with each other (Brewin & Holmes, 2003). Keane et al. (1985)
CC

indicated that emotional numbing symptoms may be avoidance behaviors to promote distress

reduction. Given that emotional numbing has been found to hinder the process of integrating and
A

resolving traumatic memories (Litz, 1992), strategies addressing emotional numbing and

dysregulation have been integrated into PTSD interventions, albeit with preliminary support

(Becker & Zayfert, 2001; Cloitre, Koenen, Cohen, & Han, 2002; Ford, Grasso, Greene,
 13

Slivinsky, & DeViva, 2018; Ford, Steinberg, Hawke, Levine, & Zhang, 2012; Reber et al.,

2013).

As an emotional regulation strategy, our proposed positive-memory intervention can

reduce hyper-focus on negative memories and enhance focus on positive memories (providing a

PT
balanced and realistic viewpoint of past experiences), thereby downregulating negative affect

and upregulating positive affect (Quoidbach et al., 2015; Rusting & DeHart, 2000). Experimental

RI
evidence supports this mood-repair effect of positive memories. Josephson (1996) demonstrated

SC
that after a sad mood induction, participants who followed a negative memory with a positive

one reported a more positive mood than participants who recalled two consecutive negative

U
memories. Another study by Rusting and DeHart (2000) indicated that following a negative

N
mood induction with positive reappraisal enhanced retrieval of more positive memories, whereas
A
focusing on negative events enhanced retrieval of more negative memories. Further, another
M

study compared mood across undergraduates who were asked to write about an intense positive

experience or a control topic; the former task was significantly associated with enhanced positive
D

mood (results were constant three months later; Burton & King, 2004).
TE

Fewer experimental studies have addressed the mood-repair effect of positive memories
EP

in clinical samples. However, results of some emerging studies on individuals with depression

severity may have applicability to PTSD interventions targeting emotional regulation via a focus
CC

on positive memories. In one study, positive memory recall resulted in decreased sad mood in

individuals who previously met criteria for at least two previous major depressive episodes
A

(Foland-Ross, Cooney, Joormann, Henry, & Gotlib, 2014). Similarly, another study found that

positive memory recall (perceived as concordant with the self) resulted in alleviation of low

mood in individuals diagnosed with major depressive disorder (Werner-Seidler, Tan, &
 14

Dalgleish, 2017). Based on comorbidity (Rytwinski, Scur, Feeny, & Youngstrom, 2013),

common underlying mechanisms (Post, Feeny, Zoellner, & Connell, 2016), and commonly

shared difficulties in retrieving positive memories (Hayes et al., 2012) between PTSD and

depression, we can expect similarities in the mood-repair effects of positive memories across

PT
these disorders. However, further experimental investigations of this mood-repair effect with

PTSD-specific samples are needed, given that certain mechanisms of memory (McNally, 2006)

RI
and emotional processing (Litz et al., 2000) are specific to PTSD (i.e., trauma-specific).

SC
Notably, the consequently enhanced positive and reduced negative affect following

retrieval of positive memories has several advantages. First, enhanced positive affect may

U
activate positive interpretations of events and additional pleasant thoughts and memories (mood-

N
congruency effect; Blaney, 1986; Rusting & DeHart, 2000; Rusting & Larsen, 1998), and
A
broaden the scope of thoughts/behaviors to include more positive content and enhance enduring
M

personal resources (broaden-and-build theory; Fredrickson, 2001). Second, enhanced positive

affect is associated with health-protective biological responses such as decreased cortisol,

D

positive health behaviors including increased physical activity, improved sleep quality, adaptive
TE

coping such as enhanced rational decision-making, better social support (reviewed in Steptoe,
EP

Dockray, & Wardle, 2009), better mental health (reviewed in Fredrickson, 2000; Lyubomirsky,

King, & Diener, 2005), and greater success in several life domains (Lyubomirsky et al., 2005).
CC

Lastly, enhanced positive affect may undo the lingering effects of negative affect (Fredrickson &

Levenson, 1998). In fact, writing about positive memories relates to physical (e.g., less sickness)
A

and emotional (e.g., feeling less upset) health benefits (King, 2001), and better self-efficacy

regarding one’s ability to regulate emotions (Wing, Schutte, & Byrne, 2006).
 15

Taken together, we propose that training individuals with PTSD symptoms to access and

process positive memories in treatment may increase the likelihood of using this as an effective

emotion regulation strategy. This practice, when it becomes habitual, could enhance positive

affect (and consequent benefits of enhanced positive affect) and prime positive thoughts and

PT
memories, ultimately resulting in improved functioning.

4.1.2. Adaptive Cognitions (Self, World, and Future; PTSD NACM symptoms). We propose that

RI
a focus on positive memory processing may help to alter negative cognitions present in PTSD

SC
capitalizing on the cognitive restructuring mechanism, as further discussed below.

PTSD theories highlight the influence of traumatic events and associated memories on

U
cognitive representations of the self, the world, and the future (Bernsten & Rubin, 2007; Foa &

N
Rothbaum, 2001; Janoff-Bulman, 1992). The cognitive-appraisal theory states that a trauma (and
A
associated memories) can alter belief structures related to self-concept; individuals may begin to
M

perceive themselves as weak, vulnerable, and unworthy, and may experience guilt about things

they did (or did not do) during the trauma (Janoff-Bulman, 1992). Further, Ehlers and Clark’s
D

(2000) cognitive model of PTSD maintenance indicates that PTSD becomes persistent when
TE

individuals interpret stressful events as currently threatening because of negative trauma-related

EP

appraisals and autobiographical disturbances of the trauma memory due to inaccurate temporal-

and place-contextualization and sensory priming (reviewed in Brewin & Holmes, 2003).
CC

Unsurprisingly, individuals with PTSD symptoms have predominantly negative self,

world, and future schemas (Berntsen & Rubin, 2006; Foa & Kozak, 1986; Janoff-Bulman, 1992)
A

and experience difficulties retrieving (specific) memories exemplifying contradictory positive

traits and aspects (McNally et al., 1995; McNally et al., 1994; Sutherland & Bryant, 2008b), both

of which are mutually influential. As an example, beliefs of unworthiness after a traumatic event
 16

may lead to difficulties accessing positive memories that contradict these beliefs, and

interpretations of previous and subsequent positive events are viewed through and influenced by

this negative self-schema (Bernsten & Rubin, 2007; Berntsen & Rubin, 2006); this in turn

enhances negative beliefs. Consequently, individuals may struggle to dispute negative

PT
maladaptive cognitions in therapy and may experience reduced positive affect (McNally et al.,

1994). Further, among individuals with PTSD severity, difficulties in retrieving specific positive

RI
memories may decrease their cognitive ability to envision the future and thereby motivation to

SC
set future goals and engage in fulfilling activities (McNally et al., 1995). For example, research

has shown that individuals with PTSD experience difficulty imagining future personal events in

U
response to positive but not negative cues (Kleim, Graham, Fihosy, Stott, & Ehlers, 2014).

N
Information from positive memories can aid cognitive restructuring techniques embedded
A
in other therapy modalities such as cognitive behavioral therapy (CBT; Beck, 1995). As an
M

example, an individual with PTSD may remember a situation wherein they were able to trust a

friend resulting in positive consequences; this belief of being able to trust others may help
D

counter an overgeneralized thought of a “lack of trust” following a traumatic event. Taken

TE

together, we propose that accessing and focusing on positive memories in PTSD treatment may
EP

prime positive and more accurate self-, world-, and future-schemas to serve as replacements and

counter maladaptive cognitive representations (PTSD NACM symptoms).

CC

4.1.3. Increasing Autobiographical Memory Specificity (AMS). We propose that accessing and

focusing on several positive memories in detail may improve positive memory AMS and thereby
A

reduce PTSD severity as discussed below in detail.

Reduced AMS relates to a history of trauma and PTSD severity (de Decker et al., 2003;

Henderson, Hargreaves, Gregory, & Williams, 2002), with some studies finding no differences
 17

for AMS in response to positive vs. negative cues (Henderson et al., 2002; Kuyken & Brewin,

1995; McNally et al., 1995; Schönfeld, Ehlers, Böllinghaus, & Rief, 2007). Unsurprisingly,

accessing specific positive memories has been shown to relate to PTSD symptom improvement.

For example, among individuals with PTSD who received CBT, improved retrieval of and access

PT
to specific positive memories in response to positive cues was associated with reduced PTSD

symptom severity (Sutherland & Bryant, 2007). Existing research provides empirical support in

RI
targeting improved AMS for PTSD interventions, mainly drawing from studies using MEST

SC
(Moradi et al., 2014; Neshat-Doost et al., 2013; Ricarte, Hernández-Viadel, Latorre, & Ros,

2012), COMET (Korrelboom et al., 2009; Korrelboom et al., 2012; Korrelboom et al., 2011), and

U
PMET (Hall et al., 2018) interventions. Although this nascent research on the application of

N
memory-based interventions to PTSD requires more exploration, it provides additional evidence
A
of the potential positive impact of improving retrieval of specific positive memories as a PTSD
M

intervention.

Notably, some caveats need to be considered for these proposed Path 1 effects. First,
D

some research indicates that depressed individuals may be unable to use positive memory recall
TE

as an effective mood-repair strategy after experiencing sad mood (Joormann, Siemer, & Gotlib,
EP

2007). In fact, among individuals with increasing depression severity, Vanderlind et al. (2017)

found that a fear of positive emotions subsequent to the recall of positive memories possibly
CC

contributed to a less mood-repair effect of these positive memories. Whether this pattern of

findings holds in individuals with PTSD needs to be empirically investigated given that positive
A

emotion regulation difficulties are also common in relation to PTSD severity (Weiss et al., in

press). In fact, among individuals with PTSD symptoms, the experience of positive emotions

following positive memory retrieval may be uncomfortable because they may consider
 18

themselves undeserving of positive emotions or may feel guilty when experiencing positive

emotions (Norman, Wilkins, Myers, & Allard, 2014); such beliefs may negatively influence their

ability and motivation to recall positive memories. Second, because memory-based interventions

(e.g., MEST; Moradi et al., 2014) include other therapeutic components such as

PT
psychoeducation, a component analysis would be needed to clarify the unique contribution of

enhanced positive AMS to therapeutic outcomes. Lastly, several proposed effects are drawn from

RI
non-clinical studies; the generalizability of these results to treatment-seeking individuals needs to

SC
be examined. Overall, these caveats require a thorough empirical investigation to identify and

modify intervention strategies aimed to capitalize on the positive effects of focusing on positive

U
memories.

4.2. N
Path 2 Effects (Figure 1) – Increasing Probability of Seeking Trauma-Focused
A
Interventions
M

Positive-memory interventions may augment and supplement trauma-focused

interventions such as PE and CPT in four ways. First, a focus on positive memories may increase
D

the ease of retrieving and processing specific positive memories (thinking about them, writing
TE

about them, and/or discussing them in detail with a therapist) through practice during and
EP

between sessions. This may prime individuals to consider a similar process with traumatic

memories in PE or CPT, and potentially transfer some of the memory processing skills to
CC

subsequently received interventions. Second, consequently, such individuals may experience

reduced fear about discussing traumatic memories in later trauma-focused interventions because
A

of practice effects and socialization into the treatment process of discussing memories in detail.

Third, consequently, this reduced fear may increase readiness to start trauma-focused

interventions. Lastly, activation of specific positive memories may trigger retrieval of other
 19

positive memories (Bower, 1981; Philippe, Lecours, & Beaulieu‐Pelletier, 2009) and increase

resilience and effective coping resources (Philippe et al., 2009). This in turn may help

circumvent therapy avoidance (Taylor & Stanton, 2007), may encourage clients to engage in

homework assignments and skills building, and may increase self-efficacy; thereby improving

PT
therapeutic alliance (Ackerman & Hilsenroth, 2003). Taken together, such hypothesized effects

may provide a positive outlook and willingness to attempt trauma-focused interventions.

RI
Some caveats need to be considered with these proposed Path 2 effects. First, clients may

SC
perceive and/or utilize the focus on positive memories as an additional behavioral and

experiential avoidance strategy for traumatic memories; such tendencies may hinder effective

U
processing of traumatic memories, reception of active components of trauma-focused

N
interventions, extinction of conditioned fear responses enhancing PTSD symptom maintenance
A
(Foa & Rothbaum, 2001), and clients’ transition to trauma-focused interventions. Notably, we
M

conceptualize the proposed positive-memory intervention as a cognitive control and emotional

regulation catalyst (versus an avoidance strategy), which will help to counter maladaptive
D

cognitions and emotions when integrated into or sequenced with trauma-focused interventions. A
TE

central mechanism of change in our proposed intervention involves eliciting positive

EP

affect/cognitions (with corresponding positive behavioral changes) which may involve

addressing the avoidance of positive thoughts, emotions, and behaviors; however this strategy
CC

does not involve breaking one’s pattern of avoidance to traumatic memories or

habituation/extinction. Overall, clinical judgement and skills are needed to ensure that the focus
A

on positive memories is not used as avoidance. Second, factors unrelated to the proposed

positive-memory intervention such as life events (e.g., change in employment status) or

insurance-related barriers (e.g., lack of coverage of additional sessions) may influence an

 20

individual’s decision to refuse, delay, or terminate subsequent trauma-focused interventions.

Empirical investigations of these factors can inform appropriate modifications to the proposed

intervention. As an example, a viable solution may be providing the positive-memory

intervention as a self-directed treatment for initial sessions given that a self-directed modality is

PT
acceptable and effective for PTSD treatment (Lange, van de Ven, Schrieken, & Emmelkamp,

2001), with a transition to therapist-directed trauma-focused work in later phases of treatment.

RI
4.3. Path 3 Effects (Figure 1) – Effects of a Dual Integrated Focus on Positive and

SC
Traumatic Memories

As an incorporated component of trauma-focused interventions, a focus on positive

U
memories may increase the ease and effectiveness of traumatic memory processing. Practice in

N
eliciting and discussing specific positive memories may transfer to specific traumatic memories.
A
An increase in the availability of positive information and experiences incompatible with
M

negative emotion networks may help modify those emotion structures (Foa & Kozak, 1986; Foa

et al., 1989; Foa et al., 1992), thus increasing the effectiveness of trauma-focused interventions.
D

Additionally, the positive memory may replace the trauma memory as the primary reference
TE

point to yield more positive interpretations of other events and to positively influence identity
EP

and self-concept (Bernsten & Rubin, 2007; Berntsen & Rubin, 2006; Janoff-Bulman, 1992).

Further, as an incorporated component of trauma-focused interventions, a focus on

CC

positive memories may have the potential to reduce dropout rates by increasing (1) positive

affect and thoughts that prime other positive experiences and memories to balance out negative
A

affect and thoughts, and (2) memory processing abilities (Bower, 1981; Philippe et al., 2009).

Subsequently, individuals may benefit from the active components of trauma-focused

interventions. Although trauma-focused interventions effectively treat PTSD (Schnurr, 2017),

 21

their lower retention rates pose a barrier to intervention effectiveness. A meta-analysis found

significantly higher odds of drop-out in trauma-focused (36%) compared to non-trauma-focused

(22%) interventions (Imel, Laska, Jakcupcak, & Simpson, 2013). Individuals may experience or

anticipate increased distress, although temporary, when processing trauma memories (McFarlane

PT
& Yehuda, 2000) and discontinue or choose to not engage in trauma-focused interventions.

Moreover, modest effect sizes for existing trauma-focused interventions justify the generation of

RI
novel and modified strategies (Foa et al., 2018).

SC
We conceptualize the incorporation of a focus on positive memories into trauma-focused

interventions as mainly before (sequential/preparatory) or during (integrated) the processing of

U
traumatic memories or formalized cognitive restructuring techniques. With a

N
sequential/preparatory approach, the therapist could start processing positive memories to prime
A
positive affect and cognitions, which could help with cognitive restructuring and/or engagement
M

in traumatic memory processing. With an integrated approach, the therapist could process

positive and traumatic memories concurrently. Preparatory techniques such as motivational

D

interviewing have found to relate to positive effects such as increased compliance and attendance
TE

for subsequently administered primary treatments (Westra & Dozois, 2006). Additionally,
EP

literature provides preliminary support for (1) PTSD interventions utilizing additional sequential

targets such as affect regulation (Cloitre et al., 2002; Cloitre, Petkova, & Wang, 2012; Ford et
CC

al., 2018; Ford et al., 2012), interpersonal regulation (Cloitre et al., 2002; Cloitre et al., 2012),

traumatic grief and moral injury (Steenkamp et al., 2011), and positive self-representations
A

(Staring et al., 2016), and (2) combined/integrated PTSD interventions using concurrent targets

(Becker & Zayfert, 2001) specifically for individuals with PTSD and other co-occurring

conditions (Flanagan, Korte, Killeen, & Back, 2016; Harned & Linehan, 2008; Najavits, Weiss,
 22

Shaw, & Muenz, 1998). Given the aforementioned support for both sequential and integrated

PTSD approaches and the question of whether standard treatments need to be augmented

(specifically for PE; Hembree & Brinen, 2009), the comparative effectiveness of a sequential

versus integrated approach using a positive-memory intervention needs to be empirically

PT
investigated.

Some caveats need to be considered for the proposed Path 3 effects. Whether eliciting

RI
and discussing positive memories facilitates the processing of traumatic memories has not yet

SC
been empirically investigated, and this technique/skill may not be applicable and relevant to

clients who are not good candidates for or do not benefit from trauma-focused interventions

U
(Cusack et al., 2016; Popiel, Zawadzki, Pragłowska, & Teichman, 2015). Further, individuals

N
may perceive the focus on positive memories to be irrelevant to the concerns they wish to discuss
A
in therapy (Schottenbauer, Glass, Arnkoff, Tendick, & Gray, 2008), and a focus on positive
M

memories may actually enhance drop-out rather than facilitate a transition to trauma-focused

interventions. Lastly, while there are potential costs to an implied increase in number of sessions
D

and clinician resources/time when incorporating a positive-memory intervention with trauma-

TE

focused interventions, the subsequently added sessions/resources may contribute to lower drop-
EP

out rates, greater speed of symptom reduction, and improved therapeutic outcomes in the long-

run (Högberg, Nardo, Hällström, & Pagani, 2011). Again, such questions need to be empirically
CC

investigated.

5. Future Directions of Clinical Relevance

A

Despite essential reasons to capitalize on positive memories, clinical intervention

research (versus cognitive and experimental psychology research) on positive memories is

sparse. The current review aims to start the dialogue about the incorporation of positive
 23

memories into PTSD interventions and the need for translational experimental research to

enhance clinical applications. Moving forward, clinical research would benefit from examining

five important areas, discussed in depth below.

First, to clarify how different memory processes are impacted in relation to PTSD’s

PT
symptoms, differences in phenomenological memory characteristics (e.g., vividness,

psychological distance) between positive versus traumatic memories among trauma-exposed

RI
individuals with PTSD should be examined. Empirical studies need to further investigate the

SC
three theoretical camps addressing the comparison of traumatic versus non-traumatic (including

positive) memories; these camps currently have mixed empirical support (Waters, Bohanek,

U
Marin, & Fivush, 2013). The trauma/fragmentation theory argues that traumatic memories are

N
impaired in several domains relative to non-traumatic memories (Porter & Birt, 2001; Waters et
A
al., 2013). The trauma equivalency theory, in contrast, proposes that trauma is remembered in
M

the same manner as other emotional experiences; hence traumatic and non-traumatic memories

are similar on several dimensions including vividness and narrative coherence (Porter & Birt,
D

2001; Waters et al., 2013). Supporting this theory, some studies have found no differences
TE

among trauma-exposed individuals for memory specificity in response to positive versus

EP

negative cues (Henderson et al., 2002; Kuyken & Brewin, 1995; McNally et al., 1995; Schönfeld

et al., 2007). Lastly, the trauma superiority viewpoint indicates that traumatic memories are
CC

more vivid and detailed than non-traumatic memories (Porter & Birt, 2001). Further, despite

extensive reviews on the nature and characteristics of traumatic memories and narratives (Crespo
A

& Fernández-Lansac, 2016; O’Kearney & Perrott, 2006), there are no systematic/literature

reviews exclusively on positive memories and narratives among trauma-exposed individuals with

PTSD. Thus, empirical investigations and systematic/literature reviews comparing positive to

 24

traumatic memories on phenomenological characteristics may highlight some distinguishing

characteristics of positive memories with relevance to clinical intervention research. Drawing

from such findings, interventions could target potentially problematic and distinct

phenomenological characteristics of positive memories to ensure that individuals benefit from

PT
our proposed positive-memory intervention.

Second, further empirical research using surveys or experimental paradigms needs to

RI
determine the extent to which trauma-exposed individuals have difficulties accessing and

SC
retrieving positive memories and factors affecting positive memory retrieval abilities; such

information could guide intervention targets to enhance the benefits of processing positive

U
memories. Similar to documented individual differences in other memory processes such as

N
working memory capacity (Just & Carpenter, 1992; Unsworth & Engle, 2007) and regulation of
A
intrusive memories following trauma (Levy & Anderson, 2008), several pre-trauma and post-
M

trauma factors may differentially influence the ability of trauma-exposed individuals to access

and retrieve positive memories. To elaborate, differences in positive memory retrieval abilities
D

may be contingent on mood (Bower, 1981; Joormann & Siemer, 2004), certain emotional
TE

regulation strategies such as rumination (Joormann & Siemer, 2004; Rusting & DeHart, 2000),
EP

being higher/lower on negative mood-regulation expectancies (Rusting & DeHart, 2000) or

neuroticism/extraversion (Rubin et al., 2008), emotional regulation skill deficits (Litz et al.,
CC

2000), differences in interpretation of events (Seidlitz & Diener, 1993), and lower frequency/lack

of positive experiences.
A

Third, a number of steps are necessary in developing and testing an intervention

impacting preliminary hypothesized mechanisms outlined in our proposed model. An

experimental pre-post design study assessing outcomes of mood and cognition changes, PTSD
 25

severity, and attitudes towards trauma-focused interventions following the administration of a

positive-memory intervention could yield pilot results for our proposed model. Future

recommended steps include conducting modified and diverse pilot replication studies (with

clinical and non-clinical samples), focus groups to develop a standardized intervention protocol,

PT
and ultimately a clinical trial to examine the proposed mechanisms and effects of this

intervention (Czajkowski et al., 2015; Rounsaville, Carroll, & Onken, 2001). Such research

RI
efforts will promote a nuanced understanding of the relation between positive memories and

SC
PTSD symptoms, and their underlying mechanisms.

Fourth, if findings from pilot studies are positive, a component analysis of the positive-

U
memory intervention could identify it’s most salient and active components influencing PTSD

N
severity. The positive-memory intervention is intended to be flexible and amenable to
A
personalized medicine. As an example, clinicians may choose to devote less time to cognitions
M

and more time to emotions in session; this may be an advantage for clients (e.g., those from a

different cultural background) who are not comfortable with the cognitive restructuring
D

framework typical of CBT (Arch & Craske, 2009). More relevant to the recent trends of
TE

unified/transdiagnostic protocols (Barlow et al., 2010; Gutner, Galovski, Bovin, & Schnurr,
EP

2016), a positive-memory intervention may have utility for other emotional disorders involving

distress- and anxiety-based components (e.g., generalized anxiety disorder), especially given that
CC

one of its proposed targets are NACM symptoms which may be common to distress-based

disorders (Contractor et al., 2014; Elhai et al., 2015). Further research can help develop and
A

refine such a positive-memory intervention protocol.

Finally, the nature and characteristics of the positive memory(ies) to be elicited requires

further investigation, given this area of research is fairly preliminary. An important component to
 26

consider is whether patients should be guided to select trauma-tainted (Bernsten & Rubin, 2007;

Berntsen & Rubin, 2006) or trauma-untainted positive memories; both types of memories may

have potential benefits. A focus on trauma-tainted positive memories could challenge black-and-

white thinking about trauma experiences and themselves. As an example, a woman in a

PT
previously abusive relationship for several years might be able to develop self-compassion for

her prior decision to stay in that relationship as a teenager, rather than feeling ashamed for that

RI
decision and avoiding all future relationships if she is able to acknowledge having both positive

SC
and negative memories. A focus on trauma-untainted positive memories may make it easier for

trauma-exposed individuals to engage in the therapy process and experience more immediate

U
benefits (Hagenaars, Mesbah, & Cremers, 2015; Yehuda, Joëls, & Morris, 2010). However,

N
because the purpose of processing positive memories is to elicit positive affect and change
A
negative cognitions, as well as to engage individuals in trauma-focused interventions, we
M

hypothesize that selecting untainted positive memories may provide the most benefits, given that

it can be difficult to challenge trauma-related maladaptive cognitions early in therapy. Further,

D

another question for empirical investigation is whether eliciting salient positive memories in
TE

initial sessions would provide therapeutic content to aid cognitive restructuring of trauma-related
EP

beliefs and effective mood-repair in subsequent trauma-focused work. This ties into the

empirical question of whether sequential versus concurrent processing of positive and traumatic
CC

memories would be most beneficial and offer maximum flexibility in the type of positive

memories chosen to be processed.

A

6. Conclusion

PTSD is detrimental to mental health, physical health, and quality of life (Schnurr,

Lunney, Bovin, & Marx, 2009). Despite the existence of efficacious interventions for individuals
 27

with PTSD, such interventions have significant drop-out rates (Imel et al., 2013) and are not

effective for all clients receiving them (Cusack et al., 2016; Loerinc et al., 2015; Popiel et al.,

2015). Moreover, veterans in particular often demonstrate only modest reductions in PTSD

symptoms following participation in trauma-focused therapies (Foa et al., 2018). Thus, there is

PT
considerable room for innovative treatments that bridge the gap between experimental research

and clinical application. Thinking outside the box and considering existing empirical and

RI
theoretical literature to improve PTSD interventions, by increasing client engagement and

SC
treatment retention and by reducing post-trauma symptomatology, is critical.

In our review, we underscore the importance and possible usefulness of capitalizing on

U
positive memories to improve PTSD intervention outcomes. Our proposed model is a clinically

N
testable framework grounded in experimental and positive/memory-focused intervention
A
research. We propose that a focus on positive memories in PTSD interventions may reduce
M

PTSD severity by enhancing positive affect and cognitions, decreasing negative affect and

cognitions, increasing AMS, and enhancing effects of trauma-focused interventions. Rightfully,

D

Fernández-Lansac and Crespo (2017) stated “we believe that these [PTSD] therapies could be
TE

complemented with interventions that facilitate a higher availability of positive memories, thus
EP

promoting the construction of a personal identity beyond the experienced trauma” (pg. 86).

Notably, the caveats mentioned for each of the Path effects need to be considered and
CC

empirically investigated in synergy with the mechanisms underlying our proposed model and

intervention. Hereby, we intend to broaden the understanding and clinical applicability of the
A

positive memory mechanisms of PTSD and improve on current evidence-based PTSD

psychotherapies.
 51

Figure:

Figure 1. Proposed Effects of Targeting Positive Memories in PTSD Interventions

PT
RI
SC
U
N
A
M
D
TE
EP
CC
A