Summary

Promotion of mental health is one of the essential roles of family physicians. However the study in this area was relatively neglected in the past. The new movement of Positive Psychology has broadened our understanding of positive emotion, virtues and meanings of life. Recent controlled studies have also proven the effects of various interventions in enhancing long term happiness level. By understanding the progress in positive psychology, family physicians would be more competent in managing patients and paving their own professional development. In this article, some recent research findings and their implications in our daily practice were discussed.

摘要

促進精神健康是家庭醫生的主要任務之一，但以往該領域的研究卻相對受到忽視。正向心理學的興起，加深了我們對正向情緒、美德和生活意義的理解。近來，一些對照研究也證實了各種干預措施有增加長期快樂感的效果。通過瞭解正向心理學的進展，家庭醫生在治療病人和自身專業發展上會更能勝任。本文就近期一些研究發現及其對日常醫療實踐的意義進行了討論。

---

Introduction

"A merry heart does like good medicine, but a downcast spirit dries up the bones" (The Bible, Proverbs 17:22).

As family physicians, we are always proud of our work being curative as well as preventive. Health promotion is one of the essences of our daily practice.¹ The concept of health is always elusive. In the words of Gordan (1958), the "positiveness" of health lies in the effort to reach a goal of perfection.² According to World Health Organization, being healthy is not just being free from diseases.³ Positive health also represents optimal functioning. These statements highlight our role in health promotion as well as illness treatment and prevention. When the idea of positive health comes to the context of psychological well-being, it arouses our attention to a very basic human necessity - happiness, or what some researchers called subjective well-being.⁴

Although the concept of happiness seems very fundamental across different human cultures, scientific research in this area was modest until recent years.

Long time ago in 1954, Maslow pointed out that the science of psychology had focused too much on the negative side of mind than the positive side.⁵ In the past few decades, overwhelming researches focused on the study of mental disorders and dysfunction. Little have been done in the study of the healthy mind.⁶ "Mental health" was perceived as mental disorder.⁷ The situation remained unchanged until the late 90s, when a group of psychologists in the United States raised the movement of Positive Psychology, which aroused lots of discussions and research attention on the question of: what makes life worth living?⁸

In this article, we will go into some important concepts in positive psychology and review some interesting research findings. In the light of these new ideas, we will discuss how our professional development and daily practice in family medicine can be benefited.

Positive psychology: more than feeling good

What is positive psychology? Sheldon and King (2001) emphasized the positiveness of the movement:

"It is nothing more than the scientific study of ordinary human strengths and virtues. Positive psychology revisits 'the average person' with an interest in finding out what works, what is right, and what is improving.⁹"

According to Seligman and Csikszentmihalyi (2002), the study of positive psychology includes three pillars.^6,10 First of all, at a subjective level, it is the study of the positive emotions in the past, the present and the future.

• Past - experiences of well-being, contentment, and satisfaction
• Present - pleasures, gratification and flow
• Future - hope and optimism

A "pleasant life" is described as one which allows consistent enjoyment of positive emotions in these three contexts.

Second is the study of positive individual traits which include the capacity for love, courage, interpersonal skill, forgiveness, perseverance, future mindedness, spirituality, high talent and wisdom etc. When someone uses his strengths and virtues to engage in doing something he likes, he enjoys a sense of fulfillment, something more than pleasure. This is what Seligman defined as an "engaged life".

Thirdly, at the group level, it concerns about civic virtues and the institutions that move individuals toward better citizenship. It is about meaning of life, using our strengths and virtues to serve something much larger then we are. This is called a "meaningful life".

On the other hand, what is not positive psychology? In many senses, it can be easily confused with "pop psychology", which is typically in lack of scientific bases.¹¹ In the past few years, a few hundred studies have started worldwide to examine the effect of emotional well-being, the elements leading to long lasting happiness and the interventions that promoted mental health and quality of life.⁸

Concepts of happiness and flow

Happiness, as we all know, is something more than instant positive affect. Many researchers like to use the term subjective well-being, which can be interpreted as frequent positive affect, high life satisfaction and infrequent negative affect.^4,12 It is a subjective phenomenon that should be defined from the perspective of the person.¹³ Researchers are interested to know how the long-term level of happiness can be modified. Obviously, it would be easier to raise one's emotion at a particular time than to make someone long-lastingly happier.¹⁴

Subjective well-being does not necessarily associate with bodily pleasure or positive affect. It is also an experience involving activities that produce no pleasant feelings at all but generate a subjective state of engagement and loss of self-consciousness.¹⁰ It is a state called flow. It is a sense of exhilaration and deep enjoyment. It happens when a person is working with a challenge at a level that meets his strength while not causing any sense of anxiety or fear.¹⁵ It is frequently described as a moment when sense of time seems distorted or slowed down. It usually comes not in our relaxing times, but rather when we are asked to stretch our mental and physical abilities. An example is the experience when a dancer deeply engages in her performance or when a football player being absorbed in his championship game. For a young surgeon, it would be the moment when he accomplished an appendicectomy on his own for the first time. Csikszentmihalyi's remarkable work in this area is very valuable for deeper understanding of this topic. (seeTable 1and Figure 1)

Character strengths and virtues

As mentioned above, one of the important areas in positive psychology is the study of human virtues. Virtues and strengths have been the focus of philosophy, religions and education studies.¹¹ Although psychologists and psychiatrists have successfully categorized various disordered mental conditions into systems such as Diagnostic and Statistical Manual of Mental disorder IV (DSM IV), study of positive virtues was relatively neglected.⁶ Recently, after systemically reviewed literatures and ideas from world religions, philosophies, cultures and histories, Seligman and Peterson published the Values in Action (VIA) which was the classification of humans virtues and strengths.¹⁶ Being referred as the "unDSM", VIA introduced 24 human character strengths grouped into 6 categories of virtues, which were widely recognized across cultures (Table 2). In their book "Character Strengths and Virtues: A Handbook and Classification", the criteria of classification, traditions of each strength, research data and the way of development of each strength were described in detail. By completing the VIA Strengths Inventory available at www.viastrengths.org, one can understand his own top strengths, regarded as the signature strengths. It is believed that identifying and exercising one's signature strengths is crucial for the development of flow and enhancement of well-being.¹⁷ The related studies and applications will be discussed later.

What contribute to happiness?

Having reviewed numerous cross-sectional and longitudinal studies, Lyubomirsky (2005) concluded that chronic happiness or well-being level was governed by 3 major factors: a genetically determined set point, circumstantial factors and intentional activities.¹⁴ Figure 2 summarized the contribution of each component.

Based on the findings of twins and adoption studies, it is widely accepted that around 50 percent of happiness level is determined by genetic and personality factors.^14,18 It is believed that everyone has a set point or a set range which is stable over time and immune to influence. Monozygotic twin studies over 10 years found that the cross-twin, cross-time correlation of happiness was 0.80. In contrast, for dizygotic twins, the correlation was very weak, only 0.07.¹⁴ Although the sense of well-being varies across time, people just quickly return to their set point. For example, a longitudinal study of lottery winners showed that, after one year, their level of happiness was no different to that of the control group. Similarly, paralytic victims of accidents could return to more or less their original level of well-being soon after the events.¹⁹

On the other hand, to our surprise, life circumstances contribute to only 8 to 15 percent of our long-term happiness.^20,21 The idea of hedonic adaptation theory maintains that people just adapt rapidly to life events and move back to their set range of happiness. Moreover, these life circumstances are difficult but not impossible to change.¹⁴

Let us go through these life circumstances one by one. First of all, wealth was shown to have only remarkably small correlation with happiness.²¹ Data suggested that once the basic material needs were met, additional income added little satisfaction to our lives. For the same reason, the happiest people need not to be the richest. According to The University of Michigan's World Values Surveys, the countries with highest rank of subjective well-being are Puerto Rico, Mexico, Denmark and then Colombia.²² For close relationships, married people are generally happier than singles, divorced or widowed, but the causation relation is not clear.²³ Those who can name several intimate friends are less likely to die prematurely and are happier than people who have few or no such relationships.^24,25 Concerning religious belief, according to studies conducted in Western countries, religiously committed people were twice as likely to report as "very happy" than those with low commitment.²⁶ Other surveys found that happiness and life satisfaction elevated with strength of religious affiliation and frequency of worship attendance.²⁸ How about physical health? Healthy individuals, especially older ones, reported slightly happier than sick ones.²⁹

So, what is the remaining 40 percent which contribute to our level of happiness? They are the intentional activities that people can alter.¹⁴

Both cross-sectional and longitudinal studies revealed that older persons tended to report higher life satisfaction and less negative affect than younger ones.³⁰ Therefore Carstensen (1995) suggested that people could learn to substantially increase their well-being by structuring their lives and pursuing particular goals that could contribute to positive emotions.³¹ Recently, various interventions were proven to be able to increase happiness. Examples are practising certain virtues, such as gratitude and forgiveness, visualizing best possible selves and making use of one's signature strengths etc.^17,32-34 Besides the nature of the exercises, some moderators factors, such as motivational and attitudinal factors, are also determinative in the process of the interventions. For example, whether or not the nature of the intervention fits with the participant's personality or interests is crucial to the outcome.¹⁴ Some of these findings and the application in family medicine practice will be discussed later.

Happiness, does it matter?

Before learning how to be happier, it is wise to know how good is being happier. Numerous longitudinal studies have shown that optimism was associated with both short and long term health outcomes. The famous nun study by Danner found a strong inverse association between positive emotion in early life and mortality in late life (p < .001). The happiest quartile lived about 6.9 years longer than the unhappiest quartile.³⁵ Another study of male Harvard students, found that pessimistic graduates had higher mortality and morbidity in midlife at both 20 and 35 years later, after controlling for initial health status.³⁶ Pessimistic explanatory style was proven to be associated with decreased cell-mediated immunity.³⁷

Positive affect and long term happiness also lead to certain psychological advantages. Fredrickson (2003) concluded, after longitudinal and experimental studies in the past 20 years, that when people felt good, they became more creative, integrative, flexible and open to new information. The effect was thought to be deep and enduring.³⁸

Although it is widely believed that success makes people happier, a recent meta-analysis revealed strong evidence that the long-term happiness and positive affect actually preceded success in work performance, relationship and health. It was found that happiness cultivated multiple psychosocial resources, skills and behaviours which led to success.³⁹

With increasing evidence, it is now well accepted that "the joyfulness of a man prolongs his days." (Sirach 30:22). Therefore, effective ways of prescribing happiness are essentially relevant to our daily practice.

Positive psychology in action - how to achieve long-lasting happiness

Let us look into details of some of the interventions that promote happiness level and their implications in our practice. Lyubomirsky separated these intentional activities or interventions into three categories.¹⁴

1. Behavioural activities: acts on kindness, applying signature strengths
2. Cognitive activities: count on blessings, forgiveness
3. Volitional activities: striving for important personal goals, devoting effort to meaningful causes

Acts of kindness

This activity was referred as random acts of kindness or "Pay It Forward". It is to pay effort to make someone happy or benefit him. It may include activities such as helping a friend with a personal problem, leading an elderly across the road, or presenting a small gift to a colleague. >From various studies, these acts were shown to boost up positive emotion and long-lasting well-being.⁴⁰ In a recent study by Lyubomirsky in 2004, students were asked to perform five acts of kindness per week, either all 5 acts in a day or five acts spreading over the one week, over a course of 6 weeks.³³ Interestingly, significant increase of well-being was found in the group who made all 5 acts of kindness in one day, but not in the group who spread the acts throughout the week. This study, on one hand, confirmed the effect of previously studies, and on the other hand suggested that summing up these small acts of kindness might make the intervention more distinguishable from participant's usual kindness behaviour and resulted in a more prominent effect on the well-being.

These findings can have important implications to our daily work. As a doctor, it is our privilege to perform kindness to somebody. Such examples can include: to praise an old man for his past contribution to the community, to spend a few more minutes to comfort an anxious mother, and to help an old lady to wear her shoes after examination. These actions might be trivial, but the power of adding up can light a beautiful shine to our work.

For our patients, it reminds us the importance of volunteer work, especially for those having psychosocial difficulties such as the unemployed. It is well known that unemployment has a significant negative impact on one's emotion and self-image. The longer the unemployment, the harder one may get a job again. Participating in volunteer work helps to maintain one's physical ability and social skill for a gainful job. Equally important is the psychological benefit. The acts of kindness involved can foster a charitable perception of others, increase the sense of interdependence and arouse awareness of one's fortune.⁴¹ The subsequent increase of happiness may help these people to re-engage in normal activities. However, many people need encouragement and motivation from others for the initiation. Family physicians are in position to encourage such initiation.

Counts on blessing

Here is a promising example of cognitive exercise for enhancing happiness. Emmons and McCullough (2003) did a series of randomized intervention studies on university students.³² In one of the three groups, students were asked to note down five things in the past week that they were grateful or thankful to. As compared to those who recorded hassles or neutral life events over the study period of 2-3 weeks, those who kept a gratitude journal had more positive affect, and were more optimistic and showed more pro-social behaviours. It is suggested that gratitude allows people to taste the positive life experience and helps them to extract good things in their life circumstances. It also enhances a positive re-interpretation of stressful or negative life experiences. Similar experiment was repeated by Lyubomirsky in 2003 over a period of 6 weeks and found that those who counted their blessings once a week, but not those who practised three times a week, showed an increase in subjective well-being, as compared to the control group.⁴¹ These lead to the idea that certain moderator factors, such as timing or adaptation due to overwhelming practice, may also contribute to the overall effect. Seligman compared exercise of gratitude visit (to write and deliver a letter of gratitude to someone you need but never properly to thank) to other interventions and found that this exercise showed the greatest amplitude on shooting up the happiness level; though the effect gradually disappeared in 3 months after the study.¹⁷

Counting on blessings is important to the psychological health of family physicians. It was not uncommon to see colleagues ventilating to each other during lunch hours about their nasty encounters at work. Although these dialogues seem to be soothing, the current data encourages us to count on those thankful events in our daily practice. For example we should appreciate the kindness of our nurse, the small gift from an old patient or the stable income we have etc. As doctors who offer help to others, we should be reminded that, at least, it is more blessed to give than to receive.

Studies had also proven that the habit of sharing good news could enhance positive emotion and interpersonal relationship.⁴² Regular blessing counting exercise can be carried out in our training seminars or lunch meetings to improve our working morale and personal well-being.

This kind of exercise, which is easy and not time-consuming, may also be a good practical tip for our patients. We have encountered quite a number of depressive patients who responded quite positively to these exercises. Counting the blessings helps patients shift their focus of attention from their misfortunes to the positive side of life.³⁴ When used skillfully, it can be an effective way of cognitive reframing for positive mental health.

Signature strengths

Seligman's group has done extensive researches on human strengths and virtues through internet. One remarkable controlled interventional study compared the effects of various intentional activities on both short-term and long-term happiness level.¹⁷ Interestingly, it was found that both the placebo exercise and exercise of identifying signature strength for 1 week enhanced the happiness level. Both of them resulted in significant increase in happiness score and decrease in depressive score immediately after the interventions, but the effect subsided one week post-test till the end of study at six months. On the other hand, another exercise involving identifying the signature strengths plus using them in a different way worked quite differently. It showed no immediate effect but significant increase of happiness level at one week post-test till the end of study at six months. It seems that the beauty of the intervention is the application of one's top strengths rather than just knowing them. Apart from the nature of the exercise, it was found that the adherence to the exercise and self-initiated continuation of the exercise after the study period (one week) were correlated with the increment of happiness level. This finding coincided with that of the studies by Lyubomirsky that certain moderator factors existed to determine the final outcome of the happiness interventions.¹⁴

As mentioned above, the experience of flow is closely related to the match of one's strengths and challenges. As family physicians, it would be meaningful for us to understand more about our own strengths and how we might use them. We may also review the flow experiences in our daily work. Flow experience may occur at time when we work hard to make a diagnosis. It may come when we are helping a family to go through a difficult moment. By reviewing these experiences, we may rediscover the satisfaction and meaning of our work. Understanding our top signature strengths may also help us pave our future development.

Concerning our patients, the concept of flow is particularly important to those suffering from chronic mood problem such as dysthymia. Many of these patients have chronic psychosocial stressors and they are devoid of engaged activities. Helping them identify their own character strengths may render them to engage in activities such as sports, games, artistic performance or voluntary work, which may increase their flow experiences and enhance their recovery. Locally, there are non-government organizations holding drama training and performance shows as rehabilitation programmes for mental patients. The previous outcomes were encouraging and had attracted much awareness.

The success of an organization, such as a family medicine practice, lies heavily on team-building. This can be done by understanding and promoting the application of top strengths of each individual colleague. The exercise is critical to the development of both individual and the whole practice. A proper match of strengths and work challenges can lead to the development of flow, engagement at work and enhancement of productivity.¹⁵

Conclusion

Positive psychology is the scientific study of conditions that contribute to the flourishing and optimal functioning of humankind.⁴³ It broadens our understanding of the issues of happiness, human virtues and meanings in life. Happiness was found to engender success at work, relationships and health. More importantly, current evidence suggests that happiness is, to a large extent, a matter of choice and certain interventions were proven to be effective in promoting it. Future studies may offer us more insight into the ways we can help our patients, and probably ourselves. As family physicians, this movement also reminds us of our role in promoting both physical health and psychosocial well-being.

Acknowledgments

The authors would like to express their gratitude and thanks to Dr David Chao and Dr Rudolph Chow for their valuable assistance and comments.

Key messages

1. Positive psychology is the scientific study of positive mental states including positive affect, virtues and meanings of life.
2. Long term happiness is governed by 3 major factors: a genetically determined set point, circumstantial factors and intentional activities.
3. To a large extent, happiness is a matter of choice.
4. Recent controlled interventional studies have proven that long term happiness could be enhanced by various intentional activities involving cognitive, behavioural or volitional adjustment.
5. The science of positive psychology offers family physicians some important insight into humanity, the importance of mental health promotion and the way we can flourish our own profession.

---

---

References