promoting health and behavior change with positive

Promoting Health and Behavior Change

with Positive Psychology

Liana Lianov, MD, MPH, FACPM, FACLM, DipABLM

Faculty DisclosuresLiana Lianov:• Scientific Advisory Board Member of Solera Health• Medical Advisory Board Member of Owaves• Founder and principal of HealthType LLC• President, Global Positive Health Institute, Inc.

Learning Objectives

1. Describe the role of positive psychology (PP) in effective health care practice

2. Identify highlights from leading scientific studies on the impact of PP interventions on health, as well as gaps in current research

3. Examine the reciprocal, reinforcing relationship between healthy lifestyles and PP strategies

4. Prescribe PP interventions as part of a comprehensive healthy lifestyle5. Facilitate health behavior change using PP in conjunction with

motivational interviewing and other techniques6. Apply PP approaches in interactions with patients

Learning Objective 1

Describe the role of positive psychology (PP) in effective health care practice

Less emphasis

More emphasis

What is Positive Psychology?

“The scientific study of positive human functioning and flourishing on multiple levels that include the biological, personal, relational, institutional, cultural, and global dimensions of life.”

—Seligman M, Csikszentmihalyi M, 2000

Slide provided by Kristen Collins

Positive Psychology Leverages…

• Positive affect • Contentment with the past• Happiness in the present • Hope for the future

• Individual virtues and strengths • Courage, compassion, integrity, curiosity, etc.

• Focuses on producing happiness, not lessening misery• Can be applied independently of mental health treatment• Produces a health asset (positive health) that can lead to

longer, healthier life

Seligman M. Flourish: A Visionary New Understanding of Happiness and Well‐Being. New York: Free Press, 2011.Seligman M, Steen TA, Park N, Peterson C. Positive psychology progress, empirical validation of interventions. American Psychologist2005;60:410‐421.

Positive Psychology Interventions and Diabetes• Positive psychological states (positive feelings and well-being) are prospectively

associated with HbA1c, fewer diabetes complications, and lower rates of associated cardiac events and mortality.

• Small studies linked to improved positive affect, greater health behavior adherence, lower blood sugar.

• Expanded research in this area is needed.

Massey CN, Feig EH, Psychological Well‐Being and Type 2 Diabetes. Current Research in Diabetes & Obesity Journal 2017;4(4):555641.

Huffman JC, DuBois CM, Millstein RA, et al. Positive psychological interventions for patients with type 2 diabetes: Rationale, theoretical model, and intervention development. Journal of Diabetes Research 2015;428349.

The Six Pillars of a Healthy Lifestyle

• Physical activity• Whole food plant based nutrition• Sleep • Avoiding risky substance use• Stress management• Positive psychology, including social connection

• Positive emotion• Engagement• Relationships• Meaning• Achievement

Lianov L. Roots of Positive Change, Optimizing Health Care with Positive Psychology. Fair Oaks, CA: HealthType LLC with the American College of Lifestyle Medicine , 2019.

Lifestyle Medicine and Positive Psychology Reinforce Each Other

Positive psychology/ positive emotion

Healthy behavior changes leading toward total well‐beingSlide provided by Kristen Collins

Health Behaviors of Happier People• Exercise • Don’t smoke • Use seat belts • Eat healthful and nourishing food • Avoid risky alcohol use

Kansky J, Diener E. Benefits of well‐being: Health, social relationships, work and resilience. Journal of Positive Psychology and Well‐being 2017;1(2):129‐169.

Positive Psychology is Key for…Managing stress & strengthening

mood disorder treatment

Healthy behaviors

Emotional well‐being

Physical health

Positive health

Successful provider‐patient interactions


Identify highlights from leading scientific studies on the impact of positive psychology interventions on health, as well as gaps in current research

Types of Positive Psychology Interventions • Gratitude• Character strengths• Positive goal setting• Optimistic thinking• Positive reminiscence• Savoring• Mindfulness• Acts of kindness• Forgiveness• Meaningful activities• 19 others: visualizing best possible self, cultivating sacred

moments, bibliotherapy, appreciation of beauty, etc.

Hendriks T, Schotanus‐Fijkstra M, Hassankhan A, et al. The efficacy of multi‐modal positive psychology interventions: A systemic review and meta‐analysis of randomized controlled trials. Journal of Happiness Studies 2019:1‐34.Hendriks T, Warren MA, Schotanus‐Dijkstra M, et al. How WEIRD are positive psychology interventions? A bibliometric analysis of randomized controlled trials on the science of well‐being. The Journal of Positive Psychology 2019;14(4):489‐501.

Effect Sizes of Multimodal Positive Psychology Interventions (PPIs) in Meta-Analysis

Hendriks, et al 2017

Boiler, at al2013

Sin & Lyubomirsky, 2009

SubjectiveWell‐Being

r=0.52 r=0.34 r=0.29

PsychologicalWell‐Being

r=0.27 r=0.20

• Average of 10 sessions over 8 weeks in clinical and nonclinical settings; majority in self-help or group format; only one individual intervention

• Small, but significant, effect size of PPIs on subjective and psychological well-being

Hendriks T, Schotanus‐Fijkstra M, Hassankhan A, et al. The efficacy of multi‐modal positive psychology interventions: A systemic review and meta‐analysis of randomized controlled trials. Journal of Happiness Studies 2019:1‐34.

Mediating Mechanisms: Why Happier Individuals Live Longer?

• Healthier behaviors • Cardiovascular health (parasympathetic influence)• Lower inflammation • Immune system strength • Longer telomeres • Better endocrine regulation

Kansky J, Diener E. Benefits of well‐being: Health, social relationships, work, and resilience. Journal of Positive Psychology and Wellbeing 2017;1(2):129‐169.

Keep Culture In Mind• Cultural differences in defining “happiness”• Cultural predispositions impact benefit from PPIs• Greater gains in well-being from PPIs among European Americans than

Asian Americans

Boehm JK, Lyubomirsky S, Sheldon KM. A longitudinal experimental study comparing the effectiveness of happiness‐enhancing strategies in Anglo Americans and Asian Americans. Cogn Emot. 2011;2(7):1263‐72.

• Rotating intervention: Acts of kindness before gratitude letter lead to greater gains in South Korean participants than US participants

• The reverse occurred when gratitude letter was done first

Layous K, Lee H, Choi I, et al. Culture matters when designing a successful happiness‐increasing activity: A comparison of the United States and South Korea. Journal of Cross Cultural Psychology 2013;44(8):1294‐1303.

Positive Psychology Framework: PERMA

P ER

MA

Positive emotions Engagement

Relationships

Achievement

Meaning

Slide contributed by Kristen Collins

Positive Emotions

P ER

MA

• Can help physicians/health professionals be more open-minded when diagnosing patients or creating action plans.

• Improve vagal tone, associated with greater heart rate variability and other physiologic benefits

Kok BE, Coffey KA, Cohn MA, et al. How positive emotions build physical health: perceived positive social connections account for the upward spiral between positive emotions and vagal tone.Psychological Science 2013;24:1123‐1132.


Positive Emotion and Healthy Lifestyle

• Forecasts behavioral engagement• Builds nonconscious motivation

• true, natural, non-imposed desire for change…not an outer should

• Is explained in the “upward spiral theory” • States that pleasant, intrinsic, natural emotions increase motivation and

positive health behaviors• Builds one’s psychological, social, and physical resources

Van Cappellen P, Rice EL, Catalino LI, et al. Positive affective processes underlie positive health behavior change. Psychol Health 2018;33(1):77‐97.

Kok BE, Coffey KA, Cohn MA, t al. How positive emotions build positive health: perceived positive social connections account for the upward spiral between positive emotions and vagal tone. Psychological Science 2013;24(7):1123‐1132

The Upward Spiral Theory of Lifestyle Change

Van Cappellen P, Rice EL, Catalino LI, et al. Positive affective processes underlie positive health behavior change. Psychol Health 2018;33(1):77‐97.

Engagement

P ER

MA

• Means finding enjoyment in an activity so much that you become completely engrossed in what you are doing or experiencing, losing track of time. This state is called “flow.”

• Increases positive neurotransmitters and hormones• Elevates well-being and general health

Czikszentmihalyi M. Flow: The Psychology of Optimal Experience. New York, NY: Harper and Row, 1990.

Eustress = Flow

Czikszentmihalyi M. Flow: The Psychology of Optimal Experience.New York, NY: Harper and Row, 1990.

Relationships P ER

MA• A longitudinal study (Harvard Adult

Development Study, began in 1938 and still ongoing) found that positive social connection was the single most important factor associated with happiness, physical health, and longevity.

• Positive relationships boost the parasympathetic nervous system, “tend and befriend” response, increase oxytocin and heart rate variability (improved vagal tone)


https://www.adultdevelopmenttsudy.org Kok BE, Coffey KA, Cohn MA, et al. How positive emotions build positive health: perceived positive social connections account for the upward spiral between positive emotions and vagal tone. Psychological Science 2013;24(7):1123‐1132.

Increase Social Connection, But Not…Social Media (SM) Use

• Study of 1,787 adults ages 19 to 32• Highest quartile of SM use per week had significantly increased odds of

depression compared with lowest quartile • adjusted odds ratio = 2.74

Lin LY, Sidani JE, Shensa A, et al. Association between social media use and depression among US young adults. Depression and Anxiety 2016;33(4):323‐331.

Social Media and Affect• Posting daily activities – subsequent improvement in positive affect• Posting venting feelings – subsequent reduction in mood and self-esteem

Berry N, Emsley R, Lobban F, et al. Social media and its relationship with mood, self‐esteem and paranoia in psychosis. Acta Psychiatr Scand. 2018;138(6):558‐570.

Meaning

P ER

MA

• People are more happy at work when they find meaning in their work.

• Finding meaningful activities outside of work could also contribute to work-life balance.

• Meaning can promote lower risk of cognitive decline, lower risk of disability, and longevity.


Roepke AM, Jayawickreme E, Riffle OM. Meaning and health: A systemic review. Appl Res Qual Life. 2014;9(4):1055‐1079.Boyle PA, Barnes LL, Buchman AS, et al. Purpose in life is associated with mortality among community‐dwelling older persons. Psychosomatic Medicine. 2009; 71:574‐579Boyle PA, Buchman AS, Bares LL, Bennett DA. Effect of a purpose in life on risk of incident Alzheimer Disease and mild cognitive impairment in community‐dwelling older adults. Archives of General Psychiatry. 2010;67:304‐310

Accomplishment

P ER

MA

• People possess a need to be strong and competent, and strive to achieve those needs.

• Feelings of accomplishment or achievement arise when using skills and making an effort in ways that leads to successful results.

Ben‐Shahar T. Happier New York City, NY: McGraw‐Hill Education, 2007., page 139.

Set Goals That Matter

• Goals that are intrinsically meaningful• Match our values and passions• “By pursuing work, education, and

relationships that yield both meaning and pleasure, we become progressively happier—experiencing not just an ephemeral high that withers with the leaves but lasting happiness with deep stable roots.”

Slide contributed by Beth Frates

Ben‐Shahar T. Happier New York City, NY: McGraw‐Hill Education, 2007.

Research Gap

• Need for translational research to test how these interventions work in non-behavioral health settings

• Need more research on how positive emotions impact each pillar of a healthy lifestyles

• Need more research on how a healthy lifestyle boosts positive emotions –mechanisms of action

• Need more research on the impact of positive activities in different subpopulations and conditions


Examine the reciprocal, reinforcing relationship between healthy lifestyles and positive psychology strategies

Reinforcing Link between Healthy Lifestyle and Positive Emotion

Physical Activity and Mood• PA boosts mood—large body of literature.• Comparable to cognitive therapy in impact on depression. (Rimer 2012)

• Slightly more effective overall when compared with standard treatments, including medication (Clooney 2013).

• Increase in psychological well-being is associated with higher physical activity—prospective study over 11 years! (Kim 2017)

Rimer J, Dwan K, Lawlor DA, et al. Exercise for depression, Cochrane Database Syst Rev. 2012 July 11; 7.

Cooney GM, dawn K, Greig CA, et al. Exercise for depression. Cochrane Database Syst Rev. 2013;9.

Kim ES, Kubzansky LD, soo J, Boehm JK. Maintaining healthy behavior: A prospective study of psychological well‐being and physical activity. Ann Behav Med. 2017;51930:337‐347.

Whole Food Plant Based Diet

ACLM recommends: • whole food, plant-

predominant dietary lifestyle

https://www.lifestylemedicine.org

Plant Based Diet and HappinessFruit & vegetable consumption

• Feeling calmer, happier and more energetic than normal• Predicted positive mood the next day• Amount needed for meaningful change:

• 7 to 8 daily servings of fruit or vegetables

Being happier: associated with greater fruit and vegetable consumption!

Fararouei M, brown IJ, Akbartabar TM, et al. Happiness and health behavior in Iranian adolescent girls. J Adolesc. 2013;36(6):1187‐92.Gardner MP, et al. Better moods for better eating? How mood influences food choice. Journal of Consumer Psychology 2014; 24(3):320‐335.Mujcic R, Oswald AJ. Evolution of well‐being and happiness after increases in consumption of fruit and vegetables. Am J Public Health. 2016;106(8):1504‐10Piqueras JA, Kuhne W, Vera‐villarroel P, et al. Happiness and health behaviors in Chilean college students: a cross‐sectional survey. BMC Public Health. 2011;11:443.White BA, Horwath CC, Conner TS. Many apples a day keep the .blues away‐‐daily experiences of negative and positive affect and food consumption in young adults. British Journal of Health Psychology. 2013;18(4):782‐798

Sleep and Mood• Univ. of Penn study:

• Subjects limited to 4.5 hours of sleep per night for one week reported feeling more stressed, angry, sad, and mentally exhausted.

• Significant improvement in mood after return to longer sleep patterns.Ideal amount of sleep = 7 to 9 hours…and unhappiness, stress can disrupt sleep

Dinges DF, pack F, Williams K, et al. Cumulative sleepiness, mood disturbance, and psychomotor vigilance performance decrements during a week of sleep restricted to 4‐5 hours per night. Sleep. 1997; 20(4):267‐277.Lopresti AL, Hood SD, Drummond PD. A review of lifestyle factors that contribute to important pathways associated with major depression: Diet, sleep and exercise. Journal of Affective Disorders. 2013; 148(1), 12‐27.


Prescribe positive psychology interventions as part of a comprehensive healthy lifestyle

Prescribing Positive Psychology Interventions (PPIs)

• Assess mood with tools such as the Patient Health Questionnaire – 4 that asks about symptoms of sadness and anxiety

• Check happiness or satisfaction with life using standard measures• Ask about current positive psychology related activities • Brainstorm new activities• Prescribe PPIs in the action plans to treat current physical, mental and

emotional health conditions• Also prescribe PPIs as part of the health maintenance and flourishing plan

for total well-being

Reference for this learning objective section: Lianov L. Roots of Positive Change, Optimizing Health Care with Positive Psychology. Fair Oaks, CA: HealthType LLC with the American College of Lifestyle Medicine, 2019.

Positive Psychology Prescriptions

Gratitude Practice Prescription• Counting blessings and related practices• Robust association with positive emotions• These positive emotions help build psychological and social resources

For: ___________________________________Date:___________________

Gratitude activity, 1-7x weekly. Dose: time to write 3 itemsKeep a method for journaling at bedside. PM: write down 3 things that happened that day for which you are grateful, or AM: write down 3 things you are looking forward to that day.

REFILL: Unlimited

______________________________________________________, M.D.

Gratitude Practice Prescription

Positive Psychology Prescriptions

Flow Prescription• Persons in flow experience high levels of happiness• Activity that produces flow needs to have these components:

• Clear goals • Balance between perceived challenges and skills• Clear and immediate feedback

For: _______________________________________ Date: __________________

Flow activities, 1-3x weekly. Dose: unlimitedFlow = being completely absorbed in an activity. What hobbies, games, work, or social activities are deeply absorbing for you? Find your “flow” activities and make time for them each week.

REFILL: Unlimited

______________________________________________________, M.D.

Flow Activity Prescription

Positive Psychology PrescriptionsMeaning and Purpose Prescription

• Associated with lowering heart disease risk• Linked to greater self care and use of preventive services, • Also associated with lower levels of disability, slower cognitive decline

and greater longevity

For: _________________________________________ Date:___________________

Meaning & purpose activities, 1-3x weekly. Dose: unlimitedMeaning & purpose = belonging to or serving something bigger than yourself. What volunteer, work, social or spiritual activities fill you with meaning & purpose? Identify what brings you meaning & purpose in life and make time for it each week.

REFILL: Unlimited

______________________________________________________, M.D.

Meaning and Purpose Activity Prescription

Positive Psychology PrescriptionsSocial Connection Prescription

• Feeling connected helps increase resilience• Micromoments of connectivity also have these types of impacts• Social connection is associated with mitigation of post-traumatic stress

symptoms, improved cancer survival, lower CVD mortality, improved overall mental health, better physical health and survival

For: _______________________________________ Date:___________________

Social connection activity, 1-3x weekly. Dose: unlimitedEach week, plan time being with the people who bring you happiness or doing social activities you enjoy. Not sure what those things are? Try something new.

REFILL: Unlimited

______________________________________________________, M.D.

Social Connection Prescription


Facilitate health behavior change using PP in conjunction with motivational interviewing and other techniques

Integrate Positive Psychology with Motivational Interviewing

During the motivational interviewing technique, when looking at the pros and cons of making change, help the patient emphasize how change will help them achieve positive goals rather than avoid negative consequences.

Reference for this learning objective section: Lianov L. Roots of Positive Change, Optimizing Health Care with Positive Psychology. Fair Oaks, CA: HealthType LLC, 2019.

Envisioning a Positive Future• Ask the patient’s vision for a positive future once a health behavior goal is

achieved• If I you showed me a video of that positive future, what would I see?• What would making this change allow you to do that you could not do

before the change?• Identify positive next steps that support them in moving toward a goal

• What is a single small thing you can change now on the road to achieving that positive future?

• Who can support you in this step and future one?• Track progress in terms of their ability to do the positive actions in their

future vision• Celebrate successes, including partial successes

Using Strengths as a Positive Psychology Tool in Health Coaching

• Help the patient identify their strengths:• Call out strengths you spot during your interactions• Ask powerful questions:

• Tell me about your past achievements• When were you at your best?• What energizes you?• Among your family and friends, what positive trait are you famous for?

• Recommend they take the free VIA Survey at viacharacter.org• Determine how the strengths can be used to achieve, support and

maintain the desired health behavior change.• Explain the benefits of using strengths:

• Increased motivation• Improved performance• Greater satisfaction

Use PERMA to Facilitate Behavior Change• Connect the desired behavior with as many of the elements of

PERMA as possible:• P—Positive emotions: notice and savor any positive feelings that arise

when doing the behavior• E—Engagement (Flow): notice how when doing the activity, one loses

track of time and surroundings and enjoys the focused attention on the activity

• R—Relationships: identify how the activity can be done with others and increase fun and helpful social interactions

• M—Meaning: pay attention to how the behavior aligns with one’s values and what is meaningful

• A—Accomplishment: Reflect on how the progress towards the goal gives a sense of accomplishment


Apply positive psychology approaches in interactions with patients

Positive Psychology Approaches in the Health Care Setting

Assessment• Measure well-being status

• Adult Hope Scale• Flourishing Scale• Subjective Happiness Scale• Satisfaction with Life Scale

• Measure positive activities: Happiness Skills Quiz

Reference for this learning objective section: Lianov L. Roots of Positive Change, Optimizing Health Care with Positive Psychology. Fair Oaks, CA: HealthType LLC with the American College of Lifestyle Medicine, 2019.

Satisfaction with Life Scale Indicate below on scale of 1 (strongly disagree) to 7 (strongly agree)

____ In most ways my life is close to my ideal. ____ The conditions of my life are excellent.____ I am satisfied with my life.____ So far I have gotten the important things I want in life.____ If I could live my life over, I would change almost nothing.

Diener E, Emmons RA, Larsen RJ, Griffin S. The Satisfaction with Life Scale. J Pers Assess. 1985;48(1):71‐75Kjell ONE, Diener E. Abbreviated three item version of the Satisfaction with Life Scale and the Harmony in life scale yield as strong psychometric properties as the original scales. Journal of Personality Assessment. Doi:10.1080/00223891.2020.1737093

Satisfaction with Life Scale (SWLS)

30 ‐ 35 Very high score; highly satisfied

25 ‐ 29 High score

20 ‐ 24 Average score

15 ‐ 19 Slightly below average in life satisfaction

10 ‐ 14 Dissatisfied

5 ‐ 9 Extremely Dissatisfied

Interpretation of Scores


Clinical Encounter• Discuss the patient’s experience with positive emotions and activities

• Frequency of being fully present• Noticing a sense of awe• Using personal strengths

• Facilitate the creation of positive activity habits• Affirm positive observations

• Point out progress made in treatment plan• Point out patient’s personal strengths

• Prescribe PPIs as part of the comprehensive treatment plan


Leverage the Health Care Team and External Resources• Partner with and refer to behavioral health professional, health coaches,

and spiritual counselors to assist the patient with developing positive habits

• Refer to community resources, such as church groups, hobby groups, classes, senior centers

• Recommend digital apps and programs• Seek websites developed by credible sources and professionals who actively update

and vet resources• Prescribe them based on patient interests and preferences

Building Positive Emotion in the Clinical Encounter

• Kick off question:• What happened in the last week that made you smile?• What in life brings you joy?• What’s a favorite activity you’ve done recently?• What is one thing you are looking forward to in the next week?• What’s something fun you’d like to do in the near future?

• Use humor• Eye contact, listening and smiling• Keep context in mind

Summary/Key Points• A healthy lifestyle has six pillars: physical activity, plant-based diet, sleep,

avoiding risky substance use, stress management, and…PERMA (positive emotion, engagement, positive relationships, meaning, and accomplishment) refers to the main elements of the positive psychology (PP) approach for increasing emotional well-being.

• Positive emotion and healthy habits have a reinforcing, reciprocal relationship.• Use of signature strengths is an additional strategy for promoting emotional

well-being.• Cultural differences impact the benefits gained from PP-based habits.• Coaching techniques can be enhanced with positive psychology approaches,

e.g. positive future vision, focus on what has been accomplished.• Positive activities can be prescribed and positive interactions and approaches

can be role modelled in the clinical encounter.

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