In this report:

Using the positivein your life

Quiz: How happyare you?

Getting in the "flow"

A meaningful life

A Harvard Medical School Special Health Report

Positive PsychologyHarnessing the power of happiness, personal strength,and mindfulness

Price: $26

SPECIAL BONUS SECTIONMindfulness: A pathto well-being

ContentsPOSITIVE PSYCHOLOGYSPECIAL HEALTH REPORT

Medical EditorRonald D. Siegel, Psy.D.Assistant Clinical Professor of Psychology, HarvardMedical School, Cambridge Health Alliance

WriterSusan Ince

ContributorSteven M. Allison, Psy.D.

Editor, Special Health ReportsKathleen Cahill Allison

Art DirectorHeather Derocher

Production EditorsMary Kenda AllenMelissa Rico

IllustratorScott Leighton

Published by Harvard Medical SchoolAnthony l. Komaroff, M.D., Editor in ChiefEdward Coburn, Publishing Director

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ISBN 978-1-933812-63-2

The goal of materials provided by Harvard Health Publicationsis to interpret medical information for the general reader.Thisreport is not intended as a substitute for personal medicaladvice, which should be obtained directly from a physician.

A science of satisfaction 2History of positive psychology 2Positive emotions and the brain 4The skeptics' view . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Defining and measuring happiness 7Is it genetic? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7The happiness/health connection 8What makes you happy? 9Quiz: How happy are you? 10Quiz: How do you seek happiness? . . . . . . . . . . . . . . . . . . . . 11Testing your happiness level 12

Your strengths and virtues 13Understanding personal character 13Defining virtues and strengths 13

Gratitude 16Studying gratitude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Counting your blessings . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Savoring pleasure 19Happiness and choice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Flow: Becoming more engaged '.' 21Defining flow 21Matching your skill level 22Flow at work _ . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22How to get in the flow 23

SPECIAL BONUSSECTION:Mindfulness 25

The meaningful life 28Do unto others. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

When times are tough 30Coping with stress 30Positive psychology in psychotherapy 31Finding assistance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Taking positive psychology beyond the individual. 34Positive relationships 34Positive communities 35

Glossary 37

Resources 38

When times are tough

Can positive psychology help you when you areanxious, depressed, or under stress? Some of the

strategies of positive psychology, such as practicinggratitude, can slow your adaptation to positive eventsso that your feeling of happiness, when receiving apay raise, for example, lasts instead of being immedi-ately replaced by the desire for the next pay raise (see"Defining and measuring happiness;' page 7). Posi-tive psychology experts suggest it may also be possi-ble to speed your adaptation to negative events so youbounce back more rapidly after an economic down-turn, health crisis, or personal loss.

Using positive psychology techniques can help youdevelop the resilience to handle difficultiesmore easily.If you develop the habit of counting your blessings, forexample, you may be better able to appreciate the goodin your life that remains even after a change in circum-stances like a job loss or a death. Greater engagementin hobbies or nature and good relationships with fam-ily and friends can be sources of support in difficulttimes. In addition, knowing your strengths, anothertenet of positive psychology (see "Your strengths andvirtues;' page B), can help you develop realistic goalswhen your life changes. And helping others, evenwhen you are struggling, can increase your positivefeelings and help you gain perspective.

Coping with stressThere is also intriguing preliminary evidence thatpositive psychology techniques, in addition to prepar-ing you for the ups and downs of life, can be valuablein times of stress, grief, or other difficulties. Here aresome examples:

a Gratitude. People dealing with an unpleasantemotional memory were given one of three writingassignments: write something neutral, write about theunpleasant event, or write about positive consequencesfrom the event that they could be grateful for (see

30 Positive Psychology

e door opens;' page- The Journal of Posi-

_ ~r~ ;":;xr~ on gratitude in theirwriting gaineC.~dos::::-e Gi3.::3.e incident, had fewer

e"\i"I'. and had less emotion-c=u.<~ ~ with participants

. de.·r~ •.=-;- ~ Emmons' landmark stud-

. hed in 2003 in the. Psychology, involved

. For three weeks,es kept a daily grat-

cou:::;~~ dailv ratin a forms about_ ,b

110sc cm:!:lting their blessings expe-f7"l?,> optimism, life satisfac-

others-and the positiverepons that significant others

participants benefited physically- raking more refreshed.

Affairs psychiatric reha-rere given the opportu-

'on \1A survey (see "Yourge 13) and receive a print-

out of their five signature strengths. The cliniciansreported in the journal Psychiatric Services in 2006that participants felt pride in their discoveries, had asense of accomplishment. and improved their moodjust by taking the inventory, Later, many of the veter-ans referred to their lists of strengths for direction andencouragement as they engaged in therapy and madeeducation and career plans for their futures.

<:1 Savoring pleasure. Positive reminiscence is notonly pleasurable, it helps people gain a new perspec-tive on current problems. In a 2008 study from theNetherlands, when depressed older adults used thetool of positive reminiscence, they not only thoughtmore positively about their past but began to evaluatethemselves, their social relationships, and their futuremore positively.

"Exercise ~:

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Flow. When you're fully engaged in activities,are less preoccupied by mundane thoughts. In

~ ition, flow experiences can lessen more disturbing- ughts. In a study published in The British Journal_-Occupational Therapy in 2006, women living with

cer had fewer intrusive thoughts about their illnessreduced stress when they had flow experiences

. e creating artwork.Meaning. In a study of patients who've had heart

"'---="-"-~>those who blamed their heart attack on othersmore likely to have a second attack in the next

_ - "ears. People who perceived some benefit in- - experience, such as appreciating life more, were

likely to have a recurrence.Mindfulness. For three decades, mindfulness-basedreduction programs (first developed at the Univer-

- • of Massachusetts Medical School) have helped reduce.: : ical and psychological symptoms in people facing a

-ety of challenges, including cancer and chronic pain._-~an example, the skin lesions of patients undergoing_-:_.~TIoletlight therapy for severe psoriasis cleared more=--.irl1Ivwhenpeople listened to an audiotaped mindful-

intervention during treatment sessions.

ltive psychologyychotherapyo t therapists, and you're likely to hear that

~ been using positive psychology for years. Many- -- ~ -deas of positive psychology have long been part- :_. hotherapy. Good therapists of all types help:? recognize their strengths and identify paths

zreater fulfillment and happiness. For exam-. ist therapy usually tries to identify women's

s::::1~ms(rather than focus on their weaknesses) and.: and validate women's feelings. Humanistic psy-

'~""""~-. emphasizes the importance of finding mean-__ ife and continuing to grow psychologically. But

~- ntly, the primary focus of a lot of psycho-"'-- •.•••..••~ T,'-as to treat mental illness by addressing nega-'==~~~aTlS of thoughts and behaviors.

lc~laDre-based therapies"'"'-'•.•.•.."--_-~~-"acceptance- based" therapies explicitly use-===:::='::::.ess, often combined with cognitive behav-

ard.edu

ioral techniques, to help people who are depressedor anxious recognize when they are having negativethoughts ("no one likes me") and to accept and watchthem dispassionately rather than getting caught up inthe negativity. Some of these therapies also stress thepositive psychology approach of identifying and actingin accordance with your values .

-1' Mindfulness-based cognitive behavioral therapy,which combines mindfulness practice with cognitivebehavioral techniques, has been successfully used totreat depression and anxiety. The best documenteduse is to prevent relapses of depression. Mindfulnesshelps people recognize when their mood is beginningto plummet, and to focus on their present experiencerather than on fears of the future or reliving past nega-tive episodes. In randomized clinical trials, mindful-ness-based cognitive behavioral therapy cut the relapserate in half for people with recurrent episodes of depres-sion. In a randomized clinical trial published in theJournal of Consulting and Clinical Psychology in 2008,people with recurrent depression who participated inan eight-week group course of mindfulness-based cog-nitive therapy were Significantly less likely to becomedepressed again than people who continued on antide-pressants without therapy. During the study, people inthe mindfulness group reported greater physical well-being and enjoyment in daily life, and 75% were able todiscontinue their antidepressant medication.

Dialectical behavior therapy (OBn has become anestablished treatment for borderline personality dis-order, a difficult-to-treat condition in which a per-son experiences extreme fluctuations in mood andin their opinions of themselves and others. Unable totolerate frustration, people with borderline personal-ity disorder often lash out, and their lives are charac-terized by. chaotic and difficult relationships and byself-destructive behaviors such as eating disorders,cutting themselves, and suicide attempts. Mindfulnessskills learned as part of DBT help patients watch theirthoughts and emotions nonjudgmentally, enablingthem to better tolerate distress and gain more controlover their reactions. In one two-year study, patientstreated with DBT had far fewer suicide attempts andpsychiatric hospitalizations, and they were more likelyto stick with their treatment.

Positive Psychology 31

Acceptance and commitment therapy (ACT) isincreasingly used to treat a remarkable range of psy-chological difficulties. While it doesn't teach mindful-ness meditation, ACT helps people to see that theirthoughts are just thoughts rather than reality and tosee themselves as the observer of the thoughts ratherthan as the "thinker:' It also helps patients to accepttheir constantly changing kaleidoscope of pleasantand unpleasant experiences and to redirect their livestoward whatever provides meaning. ACT has beenshown to lower the need for rehospitalization of psy-chotic patients, lessen social anxiety, reduce disabilitydue to pain, aid smoking cessation, and reduce high-risk adolescent sexual behavior.

Finding assistancePeople in a broad range of professions-from tradi-tionally trained mental health professionals to motiva-tional speakers to religious teachers-claim they canhelp you become happier. Several types of practitio-ners with varying credentials offer services drawingon the findings of positive psychology.

Life coachesOver the past several years, there has been a surge inthe number of people promoting themselves as "lifecoaches" or "happiness coaches" who consult withpeople in person, via scheduled telephone sessions,or through e-mail communication. Life coaches helppeople evaluate their values and goals, make plans for-- --- --areas they wish to change, and take concrete steps toput them into action. Lifecoaches do not provide treat-ment for depression, anxiety, or other mental disor-ders. No degree is required to be a life coach, and thereis no licensing requirement. However, some peoplewho practice as life coaches hold degrees and licensesin mental health fields. For example, some coaches arepsychotherapists who have partially or totally shiftedtheir practice into coaching. Recent entrants to thefield include people who have earned a master's degreein positive psychology: this training does not specifi-cally train people as therapists or coaches, but it pre-pares graduates to incorporate positive psychologytechniques into their existing practices.

32 Positive Psychology

EXERCISE #7

One door closes, one door opensRecall three times that you lost out on somethingimportant and write them down. What was the doorthat closed? What other door opened? How did youchange from that experience? Do you recognize anybenefits you are grateful for? This exercise can help yourecognize that hardships may bring benefits and can helpyou assimilate different experiences and find value andsatisfaction in your present life.

However, many life coaches hold no professionalcounseling degree or license and are trained only byone of numerous coaching institutes. While someof these programs are rigorous, others are not. Eachcoaching institute decides whom to accept and howmuch training to require for participants to earn theircertificate. In some cases, there are no prerequisitesfor entering a coaching program, and the training mayinvolve as little as a weekend seminar or watching aDVD. No state licenses coaches or restricts who cancall themselves a life coach or happiness coach. Medi-cal insurance doesn't cover the cost of using a coach(which can be hundreds of dollars a month).

Licensed mental health professionalsThese practitioners come from a variety of academicdisciplines but share knowledge of the causes of psy-chological distress and its treatment. Each field has itsown strengths.

Psychiatrists (M.D.) are medical doctors whohave attended medical school and specialized in psy-chiatric disorders. These doctors are state licensed,covered by health insurance, generally prescribemedications, and may also provide psychotherapy.

Psychiatric clinical nurse specialists (R.N.) haveearned a degree in nursing with a specialty in provid-ing psychiatric services. They often provide psycho-therapy, are usually covered by health insurance, andmay prescribe medications.

Psychologists (Ph.D., Psy.D., Ed.D.) have earned adoctoral degree in psychology. They generally pro-vide psychotherapy and may also do psychologicaltesting. Many hold state licenses to treat patients andare covered by health insurance plans. Most psycholo-

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gists do not prescribe medication. The field of positivepsychology originated with and has been developedmainly by psychologists.

Clinical social workers (U.C.S.W.) have earned amaster's degree in social work. Many hold state licensesto treat patients and are covered by health insuranceplans. They provide psychotherapy and are trainedparticularly to focus on a person's place in the family orwider community. They do not prescribe medication.

States also license a variety of other masters-levelcounselors with various areas of specialization.

Which should you choose?If you feel you are generally doing well and not strug-gling with anxiety, depression, substance problems,or other mental health issues, but would like somesupport in using positive psychology in your life, acoach may be able to help. Recognize, however, thatit's a buyer-beware situation. Ask about training andexperience, examine references, and schedule a trialsession to evaluate the coach's listening skills, knowl-edge, and compatibility before entering into any typeof contract for ongoing coaching.

Most positive psychology interventions carry littlerisk, but they may heighten your awareness of difficul-ties in your life. A coach who is not a mental health

rofessional may not be able to assist you in identify-ing problems that could benefit from medication or

chotherapy, nor be able to help you process strong_ elings that may emerge during the process. If youfeel that your thoughts, behaviors, and feelings are- terfering with your ability to function well in life,or you wish to evaluate the influence that past rela-

.onships and experiences are having on your current- ctioning, it is probably best to seek a traditionallytrained mental health professionaL

If you are intrigued by the principles and strategies'bed in this report, ask whether the therapist'sach incorporates aspects of positive psychology

":=.. -- .narvard. edu

From the body up"Healthy body, healthy mind" is an old idea buoyed by newevidence. How you treat your physical body affects yourmind and your level of happiness.

Healthy sleep and exercise habits can buoy both mind andbody. For example, in a study of working women, gettinga good night's sleep made a huge difference in how muchwomen enjoyed all types of activities during the day-farbigger than the influence of income, marital status, religion,or time pressures.

As for exercise, it turns out that many people's lifestylesinclude a natural depressant: being sedentary. Humans aredesigned for physical activity, and physical exercise hasbeen shown to enhance well-being and help prevent or siq-nificantly reduce anxiety and depression.

In a study published in Psychosomatic Medicine in 2007,when 202 people with major depression were randomlyassigned to supervised or home exercise programs, theantidepressant sertraline (Zoloft), or a placebo, four monthslater the exercisers were just as likely to have enteredremission as those taking medication.

-such as mindfulness-based cognitive therapy oracceptance and commitment therapy. Other questionsto ask:

• What is your training and experience?

• What areas do you specialize in?

• What type of treatments do you usually use withpeople in my situation?

• Do you accept my insurance plan?

• What are your fees?

• How long would you anticipate seeing me before were-evaluate how things are going?

• Can I schedule an interview or trial session prior tomaking a decision?

• What is your experience working with people withmy concerns?

Positive Psychology 33

nique of experience sampling (see "Defining flow;'page 21). In this study, couples were beeped at randomintervals and reported on their activity, mood, andsatisfaction and closeness in their relationship. Theresearchers found that the way couples spend theirtime together influences the quality of their relation-

ship. Watching television was prettyneutral, not making couples feel anybetter or worse about their relation-ship. In contrast, pursuing moreflow-inviting activities as a couple-such as sailing, hiking, learning anew skill together, or other activeleisure (including sex)-led to more

positive feelings about the relationship, which lastedfor more than five hours after the activity ended.

In a follow-up laboratory study at Western Wash-ington University in which couples solved word puz-zles together, the tasks with a flow-inviting balanceof skill and challenge (the couple could successfullycomplete them, but it took work) made the couplesfeel better about their relationships than working on apuzzle that was too easy or too hard.

Mindfulness has also been linked to happier,more resilient relationships. In the Journal of Mari-tal and Family Therapy, researchers at the Universityof Rochester reported in 2007 that higher levels ofmindfulness, as measured by people's self-ratings on15 statements related to being focused in the present,are linked to more satisfactory relationships and to agreater capacity to respond to conflicts constructivelywith less stress and better communication.

Gratitude can also improve relationship satisfac-tion. Researchers at Harvard and other universitiefound a unique way to boost gratitude among peo-ple in long-term relationships. One group of partici-pants spent 20 minutes writing about how they mettheir partner, dated, and ended up together. The oth-ers wrote about how they might never have met their

Taking positive psychologybeyond the individual

Researchers at Harvardand other universities founda unique way to boostgratitude among people inlong-term relationships.

Happiness, of course, isn't a totally solo enterprise.Your relationships can have a large impact on your

sense of well-being, and your actions and moods caninfluence the people you come in contact with. There'salso recent evidence that when you become happier,it helps those around you increase their own happi-ness. In the large Framingham HeartStudy, when people became happy,their nearby friends experienceda 25% greater chance of becominghappy, and their next -door neigh-bors had a 34% increase. In theirreport in the December 2008 issueof BMJ, researchers from the Uni-versity of California, San Diego, and Harvard Medi-cal School concluded that "people's happiness dependson the happiness of others with whom they are con-nected:' So working toward your own happiness canbenefit the people around you as well.

Positive relationshipsDay-to-day happiness in a relationship takes effort,and the techniques of positive psychology can be use-ful tools in that quest.

At the beginning of a relationship, nothing ismore fascinating for two people than learning abouteach other and negotiating the give-and-take of get-ting along. Long-term relationships can grow deeperand more intimate, but without some active atten-tion, they can also deteriorate, as people repeat thesame behaviors and anticipate the same reactionsfrom their mates.

There is some evidence that applying principlesfrom positive psychology can enhance relationships.Engaging in flow experiences together, for example,may lead to more positive feelings for each other,according to a 2008 study, published in the Journal ofPersonality and Social Psychology, that used the tech-

34 Positive Psychology www.health.harvard.ed

partner, never have started dating, and not have endedup together. Those who contemplated not being withtheir partners showed the biggest gains in relationshipsatisfaction, the researchers reported in the Journal ofPersonality and Social Psychology in 2008.

Relationships are a perfect place to introduce moreexpressions of gratitude, appreciation, and kindness.You and your partner can support each other in your

for a happy, meaningful life.

sitive communities•.1 en the American Psychological Association firstopted a focus on positive psychology, it explicitly

included the study of how institutions such as schools,employers, and providers of medical care and socialervices can encourage people to live happier, moremeaningful lives-both for the benefit of individualsand for the improved functioning of the larger organi-zations. A few examples follow:

The workplace. In 2002, the Corporate LeadershipCouncil compiled a survey of almost 20,000 employees34 companies. Their findings showed a dramatic linktween job performance and attention to strengths:.hen performance reviews emphasized what a personras doing right in the job, it led to a 36% improve-:nent in performance, while emphasizing performanceseaknesses led to a 27% decline in performance.

Matching employees with the right incentiveszan also improve performance and job satisfaction,- ording to a 2005 study reported in the Journal of

anizational Behavior. The researchers looked atat made employees in an electronics and appli-e tore happier. For employees who were intrin-

achievement-oriented, creating opportunitiesow through the combination of high skill andchallenge in work activities improved employ-ood, kept them interested in their work, and

~~._~- •••••-_-- "1 rvard.edu

inspired them to go beyond their basic job require-ments to help co-workers and the organization. Foremployees with a low need for achievement, greatersatisfaction at work might be better obtained by offer-ing them greater autonomy, more free time, or moreopportunities for camaraderie with co-workers (aswell as higher pay!).

Health care. Some clinicians have alreadyembraced the concepts of positive psychology asa preventive health strategy. Case managers work-ing to ensure that people get the medical and mentalhealth services they need have adopted a strengths-based approach that helps patients appreciate theirown strengths and assume more control over deci-sions about their care. As an example, when peoplewith recently diagnosed HIV infection met with acasemanager who helped them identify their personalstrengths and abilities and formulate a plan to get thehelp they needed, they were Significantly more likelyto get appropriate medical care.

Education. Positive psychology offers many pos-sibilities for using the concept of flow to adapt assign-ments so that each child is engaged and challenged.Identifying and building strengths can help in assess-ment, individualizing teaching methods, and counsel-ing about careers. In an ongoing controlled trial fundedthrough the U.S.Department of Education, some ninthgraders in Pennsylvania have their language-arts classessupplemented by a positive psychology curriculum thatinvolvesliterature discussions and writing assignments .Students are being tracked through graduation to seeif the intervention changes their grades, extracurricularactivities, levels of satisfaction, self-assessment of theircharacter strengths, and the occurrence of depressionand anxiety. Should these positive psychology inter-ventions prove effective, such techniques could playafuture role in reaching educational goals for childrenand adults alike.•

Positive Psychology 35