THE POWER OF POSITIVE PSYCHOLOGY FOR PHYSICIAN HEALTH

THE POWER OF POSITIVE PSYCHOLOGY FOR PHYSICIAN HEALTH AND WELL-BEING LIANA LIANOV, MD, MPH, FACPM, FACLM CHAIR, POSITIVE HEALTH AND HAPPINESS SCIENCE COMMITTEE, AMERICAN COLLEGE OF LIFESTYLE MEDICINE PRESIDENT, HEALTH AND WELLNESS DIVISION, INTERNATIONAL POSITIVE PSYCHOLOGY ASSOCIATION

DISCLOSURES FOR LIANA LIANOV, MD, MPH SOLERA HEALTH SCIENTIFIC ADVISORY BOARD

OUTCOME OBJECTIVES 1. CITE KEY FINDINGS FROM SCIENTIFIC STUDIES OF THE IMPACT OF POSITIVE PSYCHOLOGY INTERVENTIONS ON HEALTH 2. IMPLEMENT THREE BRIEF POSITIVE PSYCHOLOGY INTERVENTIONS FOR SELF-CARE 3. DEVELOP A PERSONAL WELL-BEING ACTION PLAN

4 -7 -8 Breathing BREATHE IN THROUGH YOUR NOSE FOR A COUNT OF 4 HOLD FOR A COUNT OF 7 BREATHE OUT THROUGH YOUR MOUTH FOR A COUNT OF 8 http: //www. drweil. com/drw/u/ART 00521/thr ee-breathing-exercises. html

POSITIVE PSYCHOLOGY: STUDY OF POSITIVE AFFECT, STRENGTHS AND VIRTUES THAT ENABLE INDIVIDUALS AND COMMUNITIES TO THRIVE Martin Seligman

POSITIVE PSYCHOLOGY IS KEY FOR… ü MANAGING STRESS AND BURN OUT & STRENGTHENING MOOD DISORDER TREATMENT ü HEALTHY BEHAVIORS AND PHYSICAL HEALTH ü PSYCHOLOGICAL WELLBEING ü POSITIVE HEALTH ü HEALTH PROVIDER WELLBEING AND SATISFACTION ü SUCCESSFUL PROVIDER-

PHYSICIAN STRESS • OF 875 CALIFORNIA PHYSICIANS SURVEYED, 41% (763) RESPONSE: • 53% HAD SEVERE TO MODERATE STRESS • 35% HAD NO OR OCCASIONAL EXERCISE • 34% HAD 6 OR FEWER HOURS OF SLEEP • 27% NEVER OR OCCASIONALLY ATE BREAKFAST • 13% USED SEDATIVES/TRANQUILIZERS • 4% USED MARIJUANA • 7% DEPRESSED BARZARGAN 2009

MANAGE HIGH STRESS • RELAXATION, BREATHING MINDFULNESS TECHNIQUES (CALMING) • COGNITIVE AND BEHAVIORAL TECHNIQUES • SOCIAL SUPPORT • POSITIVE PSYCHOLOGY INTERVENTIONS (EXCITING, ENGAGING)

POSITIVE EMOTION OR AFFECT

CHANGING NEGATIVE AFFECT TO BASELINE ≠ ENOUGH FOR GOOD HEALTH OUTCOMES …POSITIVE AFFECT = ASSOCIATED WITH HEALTH OUTCOMES

POSITIVE AFFECT (PA) AND HEALTH • PA = ASSOCIATED WITH: • LESS ILLNESS, LOTS OF RESEARCH ON CVD • LESS HOSPITALIZATIONS • FEWER ACCIDENTS • GREATER SURVIVAL • SELF-REPORTED FEELINGS OF HEALTH • FEELING PHYSICALLY BETTER PRESSMAN 2018

POSITIVE WORDS IN TWEETS PREDICT LOWER CVD MORTALITY • CONTROLLING FOR INCOME AND EDUCATION • BETTER THAN THE COMBINED PREDICTION OF: SMOKING, DIABETES, OBESITY, HYPERTENSION, AND SIX OTHER PREDICTORS EICHSTAEDT 2015

LIFESTYLE AND LONGEVITY: YEARS GAINED MEAN EXERCISE RANGE 3. 0 2. 1 – 4. 5 NOT SMOKING 6. 8 2. 3 – 11. 5 SUBJECTIVE WELL-BEING 6. 0 – 9. 0 DIENER 2011 7. 6

• LOTS OF WORDS DESCRIBE STATES OF PLEASURABLE ENGAGEMENT HAPPINESS • JOY • CALM …are not the same, are related, but separate • CONTENTMENT • OPTIMISM • GRATITUDE • AWE • LOVE • LIFE SATISFACTION • FLOURISHING • EACH PERSON HAS OWN MODEL OF “HAPPINESS”

IN RESEARCH: HIGH AROUSAL WORDS MATTER • WORDS REFLECT EMOTIONAL STATES (AMYGDALA) • USING HIGH AROUSAL WORDS (E. G. ENERGETIC, EXCITED, LIVELY, ACTIVE) ASSOCIATED WITH LIVING 4 TO 5 YEARS LONGER • LOW AROUSAL (E. G. CALM, PEACEFUL) WORDS DID NOT MAKE A DIFFERENCE IN LONGEVITY PRESSMAN 2018

CULTURE AND POSITIVE AFFECT • POSITIVE AFFECT IS NOT ASSOCIATED WITH THE SAME BENEFITS IN KOREAN AND JAPANESE STUDY PARTICIPANTS AS IN WESTERN/US PARTICIPANTS PRESSMAN 2014

SATISFACTION WITH LIFE SCALE (COGNITIVE EVALUATION, PREFRONTAL CORTEX) EDDIENER. COM LEIKERT 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.

MEDIATING MECHANISMS: WHY HAPPIER INDIVIDUALS LIVE LONGER? • CARDIOVASCULAR HEALTH (PARASYMPATHETIC INFLUENCE) • LOWER INFLAMMATION • IMMUNE SYSTEM STRENGTH • LONGER TELOMERES • BETTER ENDOCRINE REGULATION • HEALTHIER BEHAVIORS KANSKY 2017

HEALTH BEHAVIORS OF HAPPIER PEOPLE • EXERCISE • DON’T SMOKE • USE SEAT BELTS • EAT HEALTHY NUTRITION • LESS RISKY ALCOHOL USE KANSKY 2017

POSITIVE AFFECT (PA) AND LIFESTYLE BEHAVIORS • PA FORECASTS BEHAVIORAL ENGAGEMENT • BUILDS NONCONSCIOUS MOTIVATION • NATURAL, NON-IMPOSED DESIRE FOR CHANGE …NOT AN OUTER SHOULD • IS EXPLAINED IN THE “UPWARD SPIRAL THEORY” VAN CAPPELLEN 2017

THE UPWARD SPIRAL THEORY OF LIFESTYLE CHANGE Fredrickson 2013 Van Cappellen 2017

REINFORCING LINK BETWEEN HEALTHY LIFESTYLE AND POSITIVE AFFECT

PLANT BASED DIET FRUIT & 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! …. MORE LIKELY TO SELECT THE APPLE! MUJCIC 2016, FARAROUEI 2013, GARDNER 2014, PIQUERAS 2011, WHITE 2013

PHYSICAL ACTIVITY • 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)

SLEEP • 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 1997, LOPRESTI 2013

POSITIVE PSYCHOLOGY INTERVENTIONS

POSITIVE PSYCHOLOGY INTERVENTIONS • • • (HENDRIKS 2017) 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.

EFFECT SIZES OF MULTIMODAL PPIS IN META-ANALYSIS (HENDRIKS, IPPA 2017) Hendriks, et al 2017 Boiler, at al 2013 Sin & Lyubomirsky, 2009 Subjective Well-Being r=0. 52 r=0. 34 r=0. 29 Psychological Well-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 subj. and psych. well-being

KEEPING CULTURE IN MIND • CULTURAL DIFFERENCES IN DEFINING “HAPPINESS” • CULTURAL PREDISPOSITIONS IMPACT BENEFIT FROM PPIS • PPI GREATER GAINS IN WELL-BEING AMONG EUROPEANAMERICANS THAN ASIAN-AMERICANS BOEHM 2011 • STUDY OF ROTATING INTERVENTION ACTS : OF KINDNESS BEFORE GRATITUDE LETTER LEAD TO GREATER GAINS IN SOUTH KOREAN PARTICIPANTS THAN US PARTICIPANTS • REVERSE OCCURRED WHEN GRATITUDE LETTER WAS

Gratitude OR Acts of Kindness

GRATITUDE EXERCISE Email or text a thank you, or write 3 good things.

ACTS OF KINDNESS EXERCISE Email or text someone an offer of assistance.

SOCIAL CONNECTIVITY

PHYSIOLOGIC RESPONSE …boost the parasympathetic “tend and befriend” response Fredrickson 2008, 2013 Barbara Fredrickson

POSITIVITY RESONANCE • Increases oxytocin • Increases heart rate variability (improved vagal tone) Kok 2010, 2013

Do you make authentic, brief connections with others throughout the day?

SOCIAL CONNECTION AND LONGEVITY Adult Development Study of Harvard • 80 plus year cohort of Harvard students and inner city Boston boys • Single most important predictor of happiness and longevity is having social connections

SOCIAL MEDIA (SM) AND MOOD • 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 2016

SOCIAL MEDIA AND AFFECT • POSTING DAILY ACTIVITIES -- SUBSEQUENT IMPROVEMENT IN POSITIVE AFFECT • VENTING, POSTING FEELINGS – SUBSEQUENT REDUCTION IN MOOD AND SELF-ESTEEM BERRY 2018

Well-being boosted when in proximity to nature! Physiologic mechanisms: Reductions in DBP, heart rate, cortisol levels Park 2010, Bratman 2015, Twohig-Bennett 2018

THE HEALTH CARE PRACTITIONER CAN…

RECOMMENDED ACTIONS FROM SUMMIT • START WITH PHYSICIAN/HEALTH PROFESSIONAL HEALTH • INCREASE AWARENESS OF POSITIVE PSYCHOLOGY (PP) SCIENCE • COLLABORATE ON TRANSLATIONAL RESEARCH FOR BEST PRACTICES • INCLUDE PP TOPIC ON BOARD EXAMS AND TRAININGS • DEVELOP CONSISTENT PP TERMS, DEFINITIONS AND MEASURES

Start with: What is going well in your life? End with: What has gone well during this visit?

The Prescription of the Future Exercise: FITT Frequency: four times each week Intensity: heart rate between 100 and 140 Time: at least 30 minutes each session Type: walking Nutrition: TAF Type: cruciferous vegetables such as broccoli, kale and Brussel sprouts Amount: 1 serving (1/2 cup cooked, 1 cup fresh) Frequency: once daily Positive psychology habits: Gratitude: write down 3 people for whom you are grateful once a week Support: visit sister biweekly; contact with others throughout the day Sense of meaning: volunteer at shelter monthly

WHAT CAN YOU DO TO PROMOTE PSYCHOLOGY (PP) IN HEALTH CARE? • PROVIDE EDUCATION AND TRAINING FOR YOUR HEALTH CARE TEAMS ON THE CRITICAL ROLE OF PP IN HEALTH • PARTICIPATE IN RESEARCH TO DEVELOP EVIDENCE-BASED TOOLS, AND PRACTICES • PRESCRIBE RESEARCH-BASED PP INTERVENTIONS AND RESOURCES • FACILITATE PP HABITS AS PART OF A HEALTHY LIFESTYLE • PERSONALLY PRACTICE PP HABITS

SUMMARY • POSITIVE PSYCHOLOGY HAS A KEY ROLE IN LM: • DRIVING BEHAVIOR • PHYSICAL AND EMOTIONAL HEALTH • LONGEVITY. • HEALTHY LIFESTYLES AND POSITIVE AFFECT HAVE A REINFORCING RELATIONSHIP. • CLINICIANS CAN PRESCRIBE PP-BASED ACTIONS • COLLABORATE ON RESEARCH, DISSEMINATION AND ADVOCACY TO ADVANCE THIS ELEMENT OF CARE.

What is one thing you will do differently for yourself after this talk? • Choose an activity to boost your wellbeing • Develop a brief, specific, action plan: • what, when, how much, how often, with whom, where • Set a date to evaluate your progress • Email or text the plan to yourself!

RESOURCES • GREATER GOOD SCIENCE CENTER: GREATERGOOD. BERKELEY. EDU; GGSC. BERKELEY. EDU • GREATER GOOD IN ACTION: GGIA. BERKELEY. EDU • INTERNATIONAL POSITIVE PSYCHOLOGY ASSOCIATION: IPPNETWORK. ORG • INTERNATIONAL DAY OF HAPPINESS: HAPPINESSDAY. ORG • WORLD HAPPINESS REPORT: WORLDHAPPINESS. REPORT

positivehealth@lifestylemedicine. org act@lianalianovmd. com

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