Roots of Positive Change: Optimizing Health Care with Positive Psychology

By Liana Lianov MD MPH and Barbara Fredrickson PhD

Roots of Positive Change, Optimizing Health Care with Positive Psychology reviews the science of positive psychology and its impact on health and well-being, providing guidance to physicians and other health professionals on how to practically implement this science into clinical practice. The book is written in a format that is accessible to anyone interested in the topic and applying it to their personal well-being. The foreword by eminent positive psychology researcher, Barbara Fredrickson, sets the stage for this pioneering book, which is a breakthrough in the movement to harness positive psychology for health care. Key topics covered include activities that boost positive emotions and improve emotional well-being (such as mindfulness, gratitude practice, and acts of kindness); positive activities as part of treatment of chronic diseases; coaching health behavior change; teaching and advocating for positive psychology in health care; and promoting well-being of physicians and other health care workers. The book acknowledges that more research is needed to delineate best practices for applying positive psychology in health care, and paves the way for such research. Innovative, yet practical, this contribution to the health, medical and psychology literature will resonate as an essential reference for those aiming to make a difference in their personal health and well-being and in the lives of their patients.

• Language: English
• Publisher: BookBaby
• Release date: Dec 20, 2019
• ISBN: 9780578578897

Book preview

Association

Preface

A good physician treats the disease; a great physician treats the patient who has the disease.

- William Osler

Professor of Clinical Medicine

Cofounder Johns Hopkins Hospital

I’m thrilled to offer you this breakthrough book that introduces physicians and health professionals (hereinafter referred to as medical practitioners) on the relevance of positive psychology to health and health care, and how medical practices can optimally harness this key pillar of a healthy lifestyle. The information uniquely aims at reviewing the topic through the lens of the medical practitioner, but will be of interest to anyone seeking to promote their own well-being and that of others. The role of positive psychology (PP) in lifestyle medicine (LM) is highlighted, because healthy lifestyles, prescribed as the key treatment by LM practitioners, is intricately linked with positive emotion and emotional well-being. The topic addresses our shared humanity and the ultimate driver for seeking health and providing health care—to fully engage in and enjoy life, hence is relevant to all medical specialists and health professionals.

In response to requests for practical information about how to apply positive psychology in medical practice, we provide practical tips for assessing well-being, prescribing interventions, coaching health behaviors, conducting research, teaching, advocating for positive health care change, applying PP for our own well-being, and more. Busy medical practitioners can go directly to any chapter that covers their topic of choice for quick reference. For those who wish to fully implement PP, reading through all chapters is encouraged.

The recommendations are based on research conducted in a variety of settings often outside of health care, because the evidence base specific for health care settings is still being built. As research addresses unanswered questions, the implementation of PP in health care will evolve and best practices will emerge. We encourage interested practitioners to stay tuned to such developments and updates on the American College of Lifestyle Medicine website (www.lifestylemedice.org), the International Positive Psychology Association website (www.ippanetwork.org) and other credible resources listed at the end of this book. In the meantime, we hope you find this resource useful for transforming your health care practice to effectively foster total well-being through positive psychology strategies that benefit patients and practitioners alike.

With deep gratitude for your collective dedication to promoting health and happiness,

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

Chair, Positive Health and Happiness Science Committee,

American College of Lifestyle Medicine

President, Positive Health and Wellness Division,

International Positive Psychology Association

Vice-chair, American Board of Lifestyle Medicine

CHAPTER 1

The Evolution of Two Interdependent Fields: Lifestyle Medicine and Positive Psychology

Chapter Goal:

To describe how positive psychology (PP) can promote effective health care practice that emphasizes healthy lifestyles for prevention and treatment, as in the field of lifestyle medicine (LM).

Chapter Highlights:

•The field of lifestyle medicine (LM) emphasizes the role of healthy lifestyles in preventing and treating disease for health and well-being.

•The field of positive psychology (PP) evolved in parallel to LM with aims to leverage individual strengths and virtues to achieve flourishing and well-being.

•The interventions of these two fields have the potential to reinforce each other for achieving well-being outcomes.

•The health professional’s role in facilitating behavior change and health outcomes can be aided by leveraging PP principles and interventions.

•Not only do interventions based in PP have the potential to assist behavior change (i.e. positive emotions can boost healthy behaviors), but they can lead to direct physiological improvements.

•As the fields of LM and PP continue to evolve, closer collaboration in research and practice integration has the potential to advance both fields; future LM competencies can be revised to highlight the role of PP.

The Evolution of Lifestyle Medicine

A small group of health practitioners has been using the term lifestyle medicine since 1988. The American College of Lifestyle Medicine (ACLM) was founded in 2004 and defined LM as, … the use of evidence-based lifestyle therapeutic approaches, such as predominantly whole food, plant-based diet, regular physical activity, adequate sleep, stress management, avoidance of risky substance use and other non-drug modalities, to prevent, treat, and, oftentimes, reverse lifestyle-related chronic disease (www.lifestyle-medicine.org). However, no widely accepted definition existed until 2009, when ACLM and the American College of Preventive Medicine (ACPM) convened a panel of representatives from an array of medical specialty and health professional societies to develop a standard definition and to identify the knowledge and skill competencies physicians need in order to offer high quality lifestyle medicine services.

The definition of LM the panel developed is, The evidence-based practice of helping individuals and families adopt and sustain healthy behaviors that affect health and quality of life (Lianov & Johnson 2010). They also noted that this approach includes, but is not limited to, healthy eating, physical activity, sleep and avoiding risky substance use. This definition emphasizes the practitioner’s role in facilitating patients’ behavior change as the core of clinical practice. As health care evolves to address high costs and poor health outcomes towards a movement of value-based care, these lifestyle interventions are moving closer to center stage in a growing number of health care communities and settings beyond lifestyle medicine practice.

The lifestyle medicine national panel recommended these physician core competencies: 1) perform comprehensive lifestyle assessments, including risk factors and patient readiness to change modifiable risk factors; 2) use national guidelines in lifestyle prescriptions, when appropriate; 3) use a team approach and establish effective patient and caregiver relationships; 4) make referrals when appropriate; 5) use information technology to maximize continuity of care; 6) personally practice a healthy lifestyle and; 7) promote healthy behaviors as the foundation for clinical care and lifestyle medicine (Lianov & Johnson 2010).

The roles of health behavior change (which is closely linked to positive emotions as described in Chapter 2), emotional well-being, social support, and effective relationships are prominent elements of the competencies, and can apply not only to LM practitioners, but also other medical practitioners seeking to facilitate healthy lifestyles and improve health outcomes. Table 1 provides the complete list of the competencies, as worded by the consensus panel, and highlights the segments that relate to these elements.

Table 1: Health Behavior, Emotional Well-Being and Relationships Highlighted in the Lifestyle Medicine Core Competencies

This successful collaboration across a spectrum of medical and health professional societies to define LM and its core competencies was seen as a breakthrough for the field. Moreover, most of these competencies can be recognized as essential to primary care and a spectrum of specialties to achieve improved health outcomes and for health systems shifting to value-based care. Ultimately, effective health care is grounded in healthy lifestyle changes that can be facilitated by applying these competencies, the roots of which depend on behavior change driven by positive emotion and emotional well-being. Beth Frates highlights these drivers in her comprehensive and useful introduction to the LM field, Lifestyle Medicine Handbook, with practical recommendations in chapters on mindfulness, connection and positivity (Frates et al 2019).

The Evolution of Positive Psychology

As the field of LM was developing, a new field of psychology was being ushered into the modern era by Martin Seligman–positive psychology. This new field is defined as the scientific study of human flourishing or the strengths and virtues that enable individuals, communities and organizations to thrive; or, stated more broadly, the study of the conditions and processes that contribute to the flourishing or optimal functioning of people, groups, and institutions (Gable & Haidt 2005).

The term was coined by Abraham Maslow in 1954, who first argued that psychology was not advancing the study of human potential (Maslow 1954). Over subsequent years, other scientists showed interest; in fact, physician, philosopher and psychologist William James is considered by some as America’s first positive psychologist due to his work on optimal human functioning. But it was Seligman, when he chose PP as the central theme for the term of his presidency of the American Psychological Association in 1998, who propelled this area of study into the limelight.

Just as LM and other medical practitioners are seeking to impact health and quality of life broadly, through healthy lifestyles, positive psychologists are seeking to promote mental health and emotional well-being beyond the absence of mental illness (Srinivasan 2015). Many outstanding researchers have contributed to the field and accelerated this work. And, in recent years many clinical counselors and psychologists have been trained in formal programs such as the University of Pennsylvania’s Masters in Applied Positive Psychology (MAPP) program.

The fields of LM and PP progressed in parallel without much cross-discipline collaboration. Yet the interventions offered by each field have the potential to reinforce each other to achieve desired health outcomes. The need for accelerating the integration of the principles and science of the fields became clearly apparent during a 2017 keynote address by one of the leading PP researchers, Barbara Fredrickson, then president of the International Positive Psychology Association (IPPA), at IPPA’s 5th World Congress in Montreal. Her presentation emphasized the role of positive affect in lifestyle behaviors. Health behaviors can be influenced by positive psychological approaches, not only when PP is applied with behavior change coaching/counseling techniques, such as motivational interviewing, but also when positive affect, especially when associated with that behavior, drives unconscious motivation for change (Van Cappellen et al 2018). This research has not been widely shared with the health care community, even in the face of continuing challenges to support patients in achieving and sustaining healthy lifestyle changes.

To promote well-being and health, medical practitioners need to address mental, emotional and social health, as well as physical health. Leveraging research-informed PP principles has the potential to improve each of these health elements, and to promote an additional, independent element of health–positive health. The term positive health was coined by Seligman to signify a health attribute (with biological, subjective and functional elements) that produces longer, healthier life, and lowers disease risk factors over and above what is accomplished by traditional health care (Seligman 2008).

In response to this need to expand awareness, education and training about PP to medical practitioners, ACLM convened the Happiness Science and Positive Health Committee. The Committee aims to advance the integration of science-based PP into health care practice through reviewing and aggregating the science most relevant to health and health care, developing training programs and tools, and engaging champions across a variety of health care settings who can collaborate on research to produce a clear evidence base and best practices. This handbook is an early tool that will be updated as the research and the field evolve.

Terms and Definitions

Psychologists and medical practitioners have not yet reached consensus on definitions for a range of terms used to refer to states of happiness and well-being. Examples include subjective well-being, psychological well-being, happiness, resiliency, and flourishing. In this book, we use the term healthy lifestyle to refer to physical habits that can lead to health and well-being. We use positive psychology interventions (PPIs) for intentional (whether self-selected or prescribed by a professional) strategies, activities and behaviors that can lead to positive affect and psychological states and, in turn, are associated with healthy behavior changes and physiologic benefits. We use the term total well-being to include, not only those health areas in the World Health Organization’s definition of health (https://www.who.int), but also Seligman’s areas of positive health:

•Physical health–absence of physical risk factors and disease

•Mental health–absence of mental illness

•Emotional health–ability to cope with stress, normal self-confidence and self-esteem, resilience, optimism, ability to learn and adapt and to be flexible

•Social health–having healthy relationships

•Positive health–health asset leading to greater health and longer life achieved by behaviors based in the science of positive psychology

We also use the term emotional well-being for combined states of emotional and positive health.

Some individuals might be concerned that the PP focus could lead to Pollyanna-ish thinking and suppression of negative emotions. However, when promoting total well-being with a positive psychology approach, individuals need to be encouraged to embrace negative feelings as well as positive ones. In fact, experiencing a broad spectrum of emotions, called emodiversity, is healthy (Ong et al 2018).

The Reinforcing Nature of Healthy Lifestyles and Positive Psychology

The implementation of PP strategies by medical practitioners to assist health behavior coaching and the inclusion of PPIs in treatment plans can potentially have significant benefits. Chapter 2 reviews the salient studies that demonstrate the reinforcing relationship between PP and healthy lifestyles. Benefits of PPIs include emotional well-being and increased capacity to build supportive resources (Cohn & Fredrickson 2010; Fredrickson 2013; Fredrickson et al 2008; Kok & Fredrickson 2010; Kok et al 2013; Redwine et al 2016), adherence to healthy behaviors (Gardner et al 2014, Van Cappellen et al 2018), greater health outcomes (Cohen et al 2016; Kubzansky et al 2018; Yeung et al 2018), decreased health care utilization (Kim et al 2013), increased preventive care (Kim et al 2014), and increased longevity (Chida & Steptoe 2008; Danner et al 2001; Eichstaedt et al 2015). Wound healing, inflammation, immunity (Pressman & Black 2012; Brod et al 2014), telomere length (Blackburn 2018; Puterman & Epel 2012), and endocrine and gene regulation (Nelson-Coffey et al 2017) are among some of the physical processes and pathways that may account for the impact of positive emotion on health. Even fleeting positive micro-moments of connectivity contribute to well-being and health (Sandstrom & Dunn 2014).

The reverse is also true. Evidence suggests engaging in healthy behaviors contributes to enhanced positive emotions and states. For example, individuals who exercise and eat a diet high in vegetables report greater happiness (Jacka 2010, 2011); moreoever self-reported happiness influences food choice (Gardner et al 2014). In fact, every major healthy lifestyle modality, (e.g., eating a whole food plant-based diet, being physically active, getting adequate and high quality sleep, and avoiding risky substance use), has this reciprocal relationship with positive emotion, as described in Chapter 2. Hence, the dynamic and multiplicative impact of healthy lifestyle and habits based in PP that promotes total well-being deserves much more attention in health care settings.

Many questions remain to be answered in order to build the evidence base on how best to apply the principles of PP and use PPIs in health care settings. We briefly summarize the state of current research, as well as research gaps, in Chapter 11. Moreover, the study of PP, as with other psychology subfields, has complexities and nuances that need to be sorted out in order to develop customized interventions that are more likely to be effective in particular patient populations. We review some of these nuances in Chapter 7. One essential consideration is the aim of a specific treatment plan or intervention. Different recommendations and standards will likely evolve for different aims, among them emotional well-being, quality of life, coping with pain and recovery from illness, physical health and longevity. Leaders and medical practitioners in the movement to closely integrate PP and health care need to work with behavioral researchers to identify and appropriately frame these and other research questions.

Future Vision: Highlighting Positive Psychology in Lifestyle Medicine and Beyond

Given the significant role PPIs may play in achieving a spectrum of health care