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Happiness intervention decreases pain and depression, boosts happiness among primary care patients

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Aim: The aim of the study was to determine whether positive psychological interventions (PPIs) in a primary health care setting would improve physical and mental health over time. Background: Most treatments for depression focus on reducing symptoms rather than on creating positive states of mental health. Empirical studies to verify the efficacy of PPIs in primary health care are needed. Method: In a six-week pilot program, we invited patients in a primary health care setting with symptoms of depression to participate in groups designed to increase levels of happiness. The program involved interventions such as engaging in good deeds, writing gratitude letters, and introducing empirical research. Patients completed the SF12v2(®) at the beginning and end of the program and at three- and six-month follow-up. Measures included physical functioning, bodily pain, mental health, social functioning, and vitality. Patients also participated in focus groups to discuss their experiences. Findings: Of the 124 patients who enrolled in this pilot study, 75 completed the six-week program, and 35 participated in two follow-up assessments. Among the participants who remained for all follow-up assessments, scores improved from baseline to 6-month follow-up for health, vitality, mental health, and the effects of mental and physical health on daily activities. This subset of patients reported greater energy and more daily accomplishments, along with reductions in functional limitations. Improvements in mental and physical health and functioning were shown over a six-month period. The study provides a basis for the further investigation of PPIs in creating improvements for patients with depression in primary health care.
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Happiness intervention decreases pain and
depression, boosts happiness among primary
care patients
Louise T. Lambert Draven
1
,Nina Moliver
2
and Donna Thompson
1
1
Red Deer Primary Care Network, Alberta, Canada
2
Jamaica Plain, USA
Aim: The aim of the study was to determine whether positive psychological interventions
(PPIs) in a primary health care setting would improve physical and mental health
over time. Background: Most treatments for depression focus on reducing symptoms
rather than on creating positive states of mental health. Empirical studies to verify the
efcacy of PPIs in primary health care are needed. Method: In a six-week pilot program,
we invited patients in a primary health care setting with symptoms of depression to
participate in groups designed to increase levels of happiness. The program involved
interventions such as engaging in good deeds, writing gratitude letters, and introducing
empirical research. Patients completed the SF12v2
®
at the beginning and end of the
program and at three- and six-month follow-up. Measures included physical functioning,
bodily pain, mental health, social functioning, and vitality. Patients also participated in
focus groups to discuss their experiences. Findings: Of the 124 patients who enrolled in
this pilot study, 75 completed the six-week program, and 35 participated in two follow-up
assessments. Among the participants who remained for all follow-up assessments,scores
improved from baseline to 6-month follow-up for health, vitality, mental health, and the
effects of mental and physical health on daily activities. This subset of patients reported
greater energy and more daily accomplishments, along with reductions in functional
limitations. Improvements in mental and physical health and functioning were shown over
a six-month period. The study provides a basis for the further investigation of PPIs in
creating improvements for patients with depression in primary health care.
Key words: depression; happiness interventions; positive psychology; primary health care
Received 8 June 2013; revised 10 November 2013; rst published online 22 January 2014
Introduction
Major depression is projected to become the
largest contributor to the disease burden in high-
income nations by 2030 (Mathers and Loncar,
2006). Presently, as many Canadians suffer from
major depression as from other leading chronic
conditions, including diabetes and heart disease
(Canadian Community Health Survey, 2002).
Depression has increased 60% in Canada since
1995, becoming the fastest-rising diagnosis made
by physicians (Mothersill, 2004). Worldwide,
depression is the most costly of all diseases to treat
(World Health Organization, 2008).
Depression is strongly associated with pain (Strigo
et al., 2008; Lee and Tsang, 2009; Narasimhan and
Campbell, 2010). Patients who reported physical
symptoms were 2.510 times more likely to be diag-
nosed with a depressive disorder than other patients
(Means-Christensen et al., 2008). The utilization
rates of health care were higher among primary
care patients who reported depression and pain
Correspondence to: Louise T. Lambert Draven, PhD, c/o Red
Deer Primary Care Network, 5130-47 street, Red Deer,
Alberta, Canada T4N 1R9. Email: ltlamber@yahoo.com
Primary Health Care Research & Development 2015; 16: 114126 DEVELOPMENT
doi:10.1017/S146342361300056X
© Cambridge University Press 2014
(Katon et al., 2003; Arnow et al., 2009; Narasimhan
and Campbell, 2010) than among non-depressed
patients with comparable levels of physical illness
(Rowan et al., 2002; Katon, 2003).
The World Health Organization (1946) dened
health as a state of optimal physical, mental, and
social well-being, and not merely the absence of
disease and inrmity. Health goes beyond the
absence of pathology and must be understood in
terms of health enhancement, the development of
strengths, and the maximization of ones potential
(Duckworth et al., 2005; Becker et al., 2008; 2009).
Positive behaviors offer the best protection against
mental pathology (Duckworth et al., 2005). States
of happiness, manifested by positive emotions
and experiences, contribute signicantly to robust
health. Happier individuals had greater social
supports and were more encouraged to engage in
health screenings, physical activity, and self-care
(Ostir et al., 1998; Pressman and Cohen, 2005;
Giltay et al., 2007).
Physical health has been shown to be closely
relatedtomentalhealth(Ryffet al., 2006; Ryff
and Singer, 2008). Positive emotions were found to
mitigate the physiological and cognitive effects of
negative emotions, decrease reactivity to stress, and
improve immune system response (Frederickson
et al., 2000; Segerstrom and Miller, 2004; Fredrickson
and Branigan, 2005; Fredrickson, 2006; Bower
et al., 2009). Happiness appears to have boosted
immunity, reduced stress, and inhibited wear and
tear on the body (Howell et al., 2007), as well as
enabling individuals to make better health deci-
sions and to engage in health-promoting behaviors
(Lyubomirsky et al., 2005; Fredrickson, 2006;
Veenhoven, 2008).
Traditional interventions that focus on minimiz-
ing symptoms of depression can leave individuals
in a languishing state in which they no longer
experience depression (Karwoski et al., 2006;
Layous et al., 2011). In contrast, positive psycholo-
gical interventions (PPIs), empirically derived
activities that promote the building of positive states
(Pawelski, 2009), have been found to promote
physical health (Seligman, 2008; Fowler, 2009;
Aspinwall and Tedeschi, 2010). Building positive
states can have benets beyond the absence of
negative states, an important point given that a lack
of mental health may result in the same harmful
consequences as the presence of mental illness
(Duckworth et al., 2005; Keyes, 2005). For example,
individuals who declined from a state of ourishing
to moderate mental health were four times as likely
to have a mental illness as those who remained
in a state of ourishing, whereas declining from
moderate to languishing mental health increased the
odds ratio of mental illness 10 years later by 86%
(Keyes, 2010; Keyes et al., 2010).
In clinical samples, the use of PPIs improved
positive mood for over six months (Duckworth
et al., 2005; Lyubomirsky et al., 2011; Mongrain and
Anselmo-Matthews, 2012). Interventions included
counting blessings, planning gratitude visits, and
envisioning a persons best self. When depressed
individuals engaged in noticing three good things
and using strengths in a new way, depression
remained low for up to six months, whereas writing
a gratitude letter led to an improvement in happi-
ness up to one month later (Seligman et al.,2005).
After six weeks, a treatment group had lower
depression scores and greater life satisfaction com-
pared with a control group and kept its gains one
year later (Seligman et al., 2006). The changes in
depression scores were also higher for the treat-
ment group than for a medicated control group, and
remission rates were higher.
Nonetheless, successes are modest. For instance,
Sin and Lyubomirsky (2009) reviewed 51 interven-
tions in a meta-analysis and showed that these
indeed improved well-being (r=0.29) and helped to
reduce depressive symptoms (r=0.31) albeit with
small effect sizes. A more recent meta-analysis
of positive interventions conducted by Bolier et al.
(2013) had stricter inclusion guidelines (n=39
studies with over 6139 participants) and showed
the effect sizes to be smaller but nonetheless
signicant and sustainable over time. Specically,
subjective well-being (r=0.34), psychological well-
being (r=0.20), and depression (r=0.23) were
positively affected by PPIs with the gains main-
tained at three and six months.
PPIs can be delivered in psycho-educational
groups with quick gains (Layous et al.,2011),and
are cost effective, easy to deliver, and lack side
effects. Because the focus is on well-being, PPIs
are also less stigmatizing (Layous et al.,2011).
Nonetheless, criticisms abound. Interventions have
been cited as individualistic and based on Western
denitions of happiness (Lu and Gilmour, 2006;
Christopher and Hickinbottom, 2008; Delle Fave
et al., 2011; Uchida and Ogihara,2012). Further, the
eld has only recently acknowledged that happiness
Happiness program boosts happiness decreases pain 115
Primary Health Care Research & Development 2015; 16: 114126
can be pursued through relationships and may be
less important than religion, family, or culture
(Pedrotti, 2007; Richardson and Guignon, 2008).
Proscribing Western PPIs in more collective socie-
ties may have negative implications. For instance,
pursuing individual happiness may be harmful to
relationships (Ahuvia, 2002; Uchida et al.,2004),
especially when happiness is understood as an inter-
subjective state dened by reciprocal support.
Culture, goals, and personality must be considered
(Schueller, 2011; Sergeant and Mongrain, 2011;
Schueller and Parks, 2012; Lyubomirsky and
Layous, 2013). Thus, a uniform approach is ill
advised and practitioners should be mindful not
to implement PPIs indiscriminately or to proclaim
benets beyond what the data suggests (Kashdan
and Steger, 2011).
The use of PPIs is still in its infancy and even
more so in the eld of primary health care. The
incorporation of PPIs into this domain would
improve individual skills and lead to greater states
of physical and mental health in the overall popu-
lation (Insel and Scolnick, 2006; Seligman, 2008;
Keyes, 2010; Kobau et al., 2011). Indeed, recent
studies have shown that the experience of happi-
ness signicantly enhances the chances of recovery
from a mental disorder such as depression
(Bergsma et al., 2011). Thus, empirical studies to
verify the efcacy of these interventions in primary
health care settings are therefore needed.
Method
The purpose of this pilot study was to evaluate
changes in quality of life and perceptions of
happiness among primary health care adults after
participating in Happiness 101, a six-week PPI
program designed to treat depression and increase
well-being. The primary author (Lambert, 2009/
2012) developed the program and oversaw its
implementation within the Red Deer Primary
Care Network, a primary health care organization
in Red Deer, Alberta, Canada. The rationale for
this study was predicated on the need to deliver
effective and low-cost services that translated into
tangible immediate and sustainable mental and
physical results.
Participants were primary health care patients
over the age of 18 years. Referrals came from
primary health care physicians, mental health
counselors, or patients themselves. The program was
voluntary and offered at no cost. The Ethics Review
Board of Red Deer College granted approval to
conduct the study and all participants gave informed
consent. The study was conducted between
November 2010 and March 2012 where three six-
week programs within each calendar quarter were
offered. The study involved a quasi-experimental
quantitative evaluation and a qualitative assessment
involving focus groups. The rst author was the lead
facilitator. Up to 25 participants were allowed into
each intake.
The Health-Related Quality of Life Assessment
Tool (SF12v2
®
;Wareet al., 2002), a self-administered,
12-item health measurement scale, was used. The
SF12v2
®
measures health-related quality of life
and has been extensively evaluated in patient
populations, including those with mental health
conditions. The questionnaire includes dimensions
for both physical and mental health. Domains for
physical health include (a) physical functioning,
(b) effect of physical health on routine activities
(referred to as role physical), (c) bodily pain, and
(d) overall physical health. Mental health domains
include (a) vitality, (b) social functioning, (c) effect of
mental health on daily activities (referred to as role
emotional), and (d) overall mental health. There is
also a summary component for both domains.
Norm based, each dimension of the SF12v2
®
has
a mean of 50 and a standard deviation (SD) of 10 in
the general US population. Each 1-point differ-
ence equals 1/10 of a SD, or an effect size of 0.10.
Scores below 50 reect a health status below the
population average (Ware et al., 2002), with higher
scores representing better health. The instrument
has been proved reliable and valid with estimates
of internal consistency reliability for physical
health of 0.91 and for mental health of 0.87. The
SF12v2
®
has been useful in comparing the relative
burden of diseases and in differentiating the health
benets produced by a range of treatments
(Cheak-Zamora et al., 2009).
Study participants scored in the mild to moder-
ate depression range and a score of <42 for the
mental health component of the instrument was
considered a screening cutoff for depression
(Ware et al., 2002). Most participants reported
feelings of depression, but some sought the inter-
vention as a way of preventing relapse and living
more fully and were not considered depressed.
Participants were screened for suicidal ideation,
116 Louise T. Lambert Draven, Nina Moliver and Donna Thompson
Primary Health Care Research & Development 2015; 16: 114126
other mental health issues, and possible substance
abuse. If present, mental health counselors worked
individually with patients until the risk was mini-
mized, after which the patient was free to enter the
program. Some continued to access services for
unrelated issues (ie, parenting, workplace conicts,
smoking). A number of more severely depressed
patients were on antidepressant medication, but
data were not collected to this effect. Participants
self-reported energy levels, accomplishment of
tasks, perceptions of pain and its interference in
daily tasks, limitations in social activities, feelings
of being downhearted or depressed, and overall
health. These outcomes were measured at baseline,
at the end of the six-week program, and at three-
and six-month follow-up.
During 2-h weekly sessions, participants listened
to presentations from the empirical literature
about the science of well-being. Topics included
adaptation (Lyubomirsky, 2011), orientations to
happiness pathways (Peterson et al., 2005), ow
(Csikszentmihalyi, 1990), the broaden and build
model (Fredrickson, 2006), and the architecture of
sustainable happiness (Lyubomirsky et al., 2005).
The sessions also focused on the importance of
physical activity. To place the sessions in context, a
segment on the development of positive psycho-
logy was included so that patients could under-
stand the type of treatment they were receiving.
Group discussions, along with written or verbal
in-class activities and prescribed homework,
facilitated the delivery of information. Thirteen
PPIs were introduced, all of which were based on
available literature. Examples include engaging in
three good deeds and writing a gratitude letter
(Duckworth et al., 2005; Seligman et al., 2005),
using mindfulness (Brown et al., 2007), and savor-
ing (Bryant and Veroff, 2006). Table 1 shows the
full set of weekly interventions. The program
concluded with a social event to which all past and
present participants were invited.
Quantitative assessments were based on the
results of the SF12v2
®
administered at baseline,
end of program, three- and six-month follow-up.
Analyses of variances (ANOVAs) were used to
compare baseline scores between individuals
who left the study before the end of the program,
those who completed the program but did not
participate in follow-up assessments, and those who
completed follow-up assessments. Changes for each
subscale of the instrument were also evaluated. The
distribution of the scores for individuals who com-
pleted the full follow-up assessments was sufciently
normal for the performance of parametric statistical
analyses. Therefore, repeated-measures ANOVAs
with an αsignicance level of 0.05 were used to
evaluate the changes over time. Pairwise analyses for
multiple comparisons were conducted. Bonferroni
corrections were not performed because of the
nature of the analysis and the number of sub-
scales used (Stanovich, 1988). After baseline scores
were compared, the statistical analysis included
only the 35 participants who completed all four
assessments.
For the qualitative evaluation, two focus groups
from the rst six intakes were conducted to dis-
cover how participants experienced Happiness 101
and how they compared the intervention with
other therapies. An independent facilitator was
enlisted for this purpose in November 2010 and
again in February 2011. Both focus groups took
place before the nal social event at the conclusion
Table 1 Weekly interventions
Week Intervention Empirical source
1 Mindfulness Brown et al. (2007)
Time control Flaherty (2003)
2 Goal setting; reducing over-thinking Lyubomirsky et al. (2006), Lyubomirsky and Tkach (2003)
3 Three good deeds; self-talk; optimism Carver et al. (2010), Hardy et al. (2001), Lambert (2009/2012)
4 Writing and thinking about positive experiences Burton and King (2004)
Savoring Bryant and Veroff (2006)
Gratitude letter and visit Duckworth et al. (2005), Seligman et al. (2005)
5 Best possible self Kurtz and Lyubomirsky (2008), Sheldon and Lyubomirsky (2006)
Planning a date Lambert (2009/2012)
6 Counting blessings and three good things Seligman et al. (2005)
Happiness program boosts happiness decreases pain 117
Primary Health Care Research & Development 2015; 16: 114126
of the six-week program. All comments were
audiorecorded and transcribed verbatim.
Results
Between November 2010 and March 2012, 665
referrals were received into the program, including
133 males (20%). The mean age was 45 years. Of
referred patients, 318 (48%) were registered into a
session. The program completion rate was 71%.
Of the six classes offered for each program, parti-
cipants attended an average of 3.6 classes. One
hundred and twenty-four participants completed
baseline questionnaires. We then conducted
assessments at six weeks (n=75), three months
(n=36), and six months (n=35). Table 2 shows
the gender and age distributions for each stage of
the program.
Quantitative measures
At baseline, all mean scores for mental and
physical health were below the US norm of 50. The
lowest scores were for role emotional (ie, the effect
of mental health on daily activities), overall mental
health, and social function. The highest scores
were for physical functioning. Table 3 shows the
mean scores for mental and physical health at each
assessment interval. Table 4 shows the inter-
correlations for all outcome measures at six-month
follow-up.
Three groups were considered in baseline com-
parisons: participants who withdrew before the
end of the study, participants who completed the
study but either declined or were unavailable to
participate in the three-month follow-up assess-
ment, and participants who completed all follow-up
assessments. There were no signicant differences
in any baseline measures between these three
groups, although the large rate of attrition, further
identied in the limitations section, may be sugges-
tive of some differences. When participants who
completed the six-week study were compared with
all other participants, regardless of whether they
completed the follow-up assessments, there were no
signicant differences in any baseline scores.
The percentage of at-risk patients declined from
67% at baseline to 26% at six-month follow-up
Table 3 Physical and mental health, mean scores at assessment intervals
Dimension Baseline Six weeks Three months Six months
Physical function 44.44 ± 13.37 45.43± 11.14 46.89 ± 11.37 47.39 ± 10.19
Role physical 39.14 ± 13.14 44.41± 10.25 44.54 ± 10.97 47.61 ± 9.73
Body pain 41.13 ± 14.68 47.25± 11.33 46.09 ± 10.99 47.25 ± 11.59
General health 39.82 ± 10.82 43.33± 10.09 46.71 ± 11.01 46.59 ± 8.63
Physical health summary 43.71± 14.34 46.29 ± 11.01 46.72 ± 10.98 47.98 ± 11.09
Vitality 40.85 ± 10.57 47.46 ± 10.77 50.34 ± 10.45 48.04 ± 9.29
Social function 38.67 ± 11.52 44.45 ± 11.44 44.45 ± 10.34 45.90 ± 11.98
Role emotional 35.79 ± 10.43 40.10 ± 11.91 43.45 ± 10.88 46.55 ± 9.35
Mental health 38.24 ± 10.84 46.08 ± 10.08 46.78 ± 9.51 45.38 ± 7.84
Mental health summary 36.53 ± 11.28 43.83 ± 12.27 46.00 ± 9.88 45.91 ± 9.76
n=35. Figures are given as M± SD.
Table 2 Gender and age distributions of participants at each stage of program
Time nFemales Males Mean age Age range
Baseline 124 101 (81%) 23 (19%) 48 1979
End of program (six weeks) 75 60 (80%) 15 (20%) 50 1979
Three-month follow-up 36 27 (75%) 9 (25%) 54 1979
Six-month follow-up 35 27 (77%) 8 (23%) 53 1979
118 Louise T. Lambert Draven, Nina Moliver and Donna Thompson
Primary Health Care Research & Development 2015; 16: 114126
using 42 as the cutoff score for identifying patients
at risk for depression. This decline was clinically as
well as statistically signicant. Declines were
greater among males than among females. Among
the general US population, 20% are considered at
risk for depression. Figure 1 shows the change in
the percentage of participants at risk from baseline
to follow-up.
The power of the study was β=0.94, assuming
a medium effect size. The results of repeated-
measures ANOVAs showed signicant differences
in scores of role physical, general health, vitality,
role emotional, mental health, and mental health
summary over the three time intervals. Table 5
shows the test statistics for dimensions with signi-
cant changes over time.
For health dimensions with signicant overall
changes, pairwise analyses were performed to
determine the signicance of the changes over each
time interval. Table 6 demonstrates the results of
the pairwise analyses. Of note, with the exception
of a signicant change in role emotional between
six weeks and six-month follow-up, all signicant
changes occurred only with respect to baseline
scores. Signicant improvements occurred for all six
dimensions between baseline and six-month follow-
up, and for ve of the six dimensions (with the
exception of role physical) between baseline and
three-month follow-up. Signicant improvements
occurred for vitality, mental health, and mental
health summary between baseline and six weeks.
Although the overall change for social function
was not signicant, P=0.10, pairwise analyses
showed a signicant increase in social function
between baseline and three-month follow-up,
P=0.04, and between baseline and six-month
follow-up, P=0.01. There was a signicant inverse
Table 4 Intercorrelations for outcome variables at six-month follow-up
Measures Physical
function
Role
physical
Body
pain
General
health
Vitality Social
function
Role
emotional
Role physical 0.65*** –––
Body pain 0.59*** 0.47** ––
General health 0.46** 0.62*** 0.34*
Vitality 0.46** 0.64*** 0.45** 0.65***
Social function 0.56*** 0.57*** 0.33 0.46** 0.56***
Role emotional 0.14 0.38* 0.18 0.16 0.42* 0.48**
Mental health 0.09 0.23 0.06 0.02 0.47** 0.50** 0.64***
n=35.
*P<0.05.
**P<0.01.
***P<0.001.
Figure 1 Comparison of percentage of participants at
risk for depression from baseline to follow-up
Table 5 Multivariate analysis of health dimensions with
signicant changes over time
Dimensions WilksλF
(3,32)
P-value
Role physical 0.78 2.97 0.047
General health 0.78 3.01 0.044
Vitality 0.64 5.93 0.002
Role emotional 0.51 10.32 <0.001
Mental health 0.71 4.42 0.010
Mental health summary 0.61 6.98 0.001
n=35.
Happiness program boosts happiness decreases pain 119
Primary Health Care Research & Development 2015; 16: 114126
correlation between the physical health summary
score and the mental health summary score at
baseline, n=124, r(122) =0.19, P=0.03. How-
ever, these two scores were not signicantly corre-
lated at the other three time points.
Focus groups
Focus groups were conducted with 24 partici-
pants from the rst six Happiness 101 intakes. The
rst question presented to focus group participants
was, What was your experience of Happiness 101?
What was it like?Overall, patients reported the
Happiness 101 program to be a very positive
experience, in sharp contrast to previous types of
therapies they had received in the past for
depression. Comments were as follows:
Looking at the positive sidein teaching us how
to move forward rather than focusing on the
pasthas been revolutionary a wow moment
This is what we need do within society as a
whole. (Participant #3, female, age 49)
The program was an enlightening mind frame
change from previous groups that delved into
past experiences. This was forward thinking.
(Participant #7, female, age 49)
It was a joy to come each week. I looked forward
to homework and had a desire to get better.
I needed new tools to get better. I needed to
reach out and learn new ways to help myself.
I had been down too long. (Participant #8,
female, age 51)
I didnt know that a course like this existed. The
course went way beyond my expectations.
(Participant #12, male, age 31)
I got very depressed when I became ill and I was
referred to a psychiatrist. My treatment was
entirely focused on my depression, and this
course was focused entirely on my happiness.
I always left my psychiatrist feeling worse than
when I went (Participant #17, female, age 46)
As participants learned and used the 13 PPIs,
they were asked what they retained from the pro-
gram and which (if any) techniques they continued
to use by asking, What are you doing differently as
a result of participating in this program? How have
you learned to sustain these changes?Answers
included the following:
Mindfulness This was pivotal. I try to do this
several times a day. Applying mindfulness is a
new technique. Being able to switch to focus on
whats happening around me has been different.
(Participant #3, female, age 49)
JournalingI now write about more action-
oriented items, plan ahead, and reect on the
Table 6 Signicance of changes over time, pairwise analyses
Health dimensions Time measure Baseline Six weeks Three months
Role physical Six weeks 0.09 ––
Three months 0.06 0.96
Six months 0.004 0.19 0.22
General health Six weeks 0.20 ––
Three months 0.02 0.20
Six months 0.008 0.13 0.96
Vitality Six weeks 0.02 ––
Three months <0.001 0.33
Six months 0.006 0.82 0.35
Role emotional Six weeks 0.14 ––
Three months 0.002 0.24
Six months <0.001 0.02 0.20
Mental health Six weeks 0.009 ––
Three months 0.004 0.76
Six months 0.001 0.74 0.55
Mental health summary Six weeks 0.03 ––
Three months 0.001 0.44
Six months <0.001 0.42 0.97
n=35. Signicant differences are in boldface, α=0.05.
120 Louise T. Lambert Draven, Nina Moliver and Donna Thompson
Primary Health Care Research & Development 2015; 16: 114126
positive. I often think and write about the three
good things that have happened to me today.
(Participant #7, female, age 49)
I stopped over-thinking. I learned to make a
decision and stick to it. I always went over and
over my decisions and ended up with stomach
pains. I catch myself and purposefully think
about something else that doesnt stress me out.
(Participant #4, male, age 20)
Setting goalsI had never set goals. I attained
things by chance in the past. If I needed a job,
I got one, and things worked out. This had been
a stressful year, with situations not working out,
and setting small goals that are attainable will
work for me. This was a big learning. (Partici-
pant #12, male, age 31)
I was a wallower. I have learned to be proactive
and am now doing things. I am more active
getting up and doing small projects. This is
working for me. (Participant #19, male, age 53)
I did my homework every week...thats how
committed I was. Practicing what I learned was
important. (Participant #20, female, age 44)
I am healthier because of my positivity. I havent
caught a cold lately, and I usually do. (Partici-
pant #8, female, age 51)
I smile more and have been told this. (Partici-
pant #17, female, age 46)
Of particular interest were the experiences of
some participants who were taking antidepressant
medication before or during the program. Some
participants felt they still required pharmaceutical
intervention, as the group did not meet all of their
needs, whereas others reported feeling that medi-
cation was complementary to their treatment. A
third view was that medication or hospitalization
was not sufcient and that learning the skills to
be happy was essential. Overall, participant state-
ments suggested that a balanced and careful
response to the use of medication should involve
the patients wishes as well as the acquisition of
skills to generate well-being. Comments included
the following:
I am on medication and have been to counsel-
ling. My medication has been increased and may
be at the right level now. I was having problems
with memory. Mindfulness intervention has
helped me to be more focused. I am more
relaxed. I can gather my thoughts better. I think
the medication and Happiness Group strategies
are working complementarily. (Participant #20,
female, age 44)
I have just started medication this past weekend.
The Happiness Group was not enough. (Partici-
pant #4, male, age 20)
I am still on my medication and will be for some
time, but this really helped bring perspective to
my unhappiness. (Participant #7, female, age 49)
My psychiatrist wanted me to take pills for
my depressionI was never offered a choice and
I absolutely wanted another alternative to
medication. I went back to my family physician
and was then referred to this course. (Participant
#17, female, age 46)
I need my medication because I was suicidal.
[But] my doctor emphasized that I needed to
look beyond medication in helping myself get
better. This course gave me a different perspec-
tive other than the information I was receiving in
the hospital where I was admitted with depres-
sion. I left the hospital on my ownI received so
much more from this course. (Participant #19,
male, age 53)
Many patients had been in previous forms
of counseling before attending Happiness 101.
How Happiness 101 differed from other types of
counseling and in what ways was sought. Almost
all participants agreed that the positive psycho-
logical approach was dramatically different and
that the group offered unexpected, yet highly
welcomed, benets.
I got tired of always answering question in other
therapy: Why do you think this happened to
you? (Participant #20, female, age 44)
I was excited to go home from class and try
lessons, and I looked forward to coming back.
Some classes I have attended have depleted
your energy and made you feel more depressed.
The class was energizing. (Participant #3, female,
age 49)
When I was rst referred to this class, I didnt
want to go to another group therapy class. I had
a bad experience previously where I just listened
to other peoples problems. This view only lent
itself to my feeling more depressed. It was
different to have people share things that made
them happy and not sad. (Participant #7, female,
age 49)
Happiness program boosts happiness decreases pain 121
Primary Health Care Research & Development 2015; 16: 114126
There was too much focus in other groups as to
what is making you sadthis was about becom-
ing happy. (Participant #12, male, age 31)
I was convinced that I needed to x the things
from the past that bothered meI was forced to
relive past experiences, rather than moving on.
Why do I have to deal with old issues? I found
out this is not the case anymore. (Participant #10,
female, age 60)
In past group experiences, I just cried the whole
time. (Participant #8, female, age 51)
This was my rst group experience, but in
individual therapy I cried the whole time. Louise
emphasized that we didnt need to cry. I am
learning to be happy about my husband
and children and not to think of them as
sources of unhappiness. (Participant #13, female,
age 42)
I dont like a group situation, but I started to
enjoy coming to these groups because I was
learning so much. (Participant #19, male, age 53)
This perspective doesnt bring you down. It lifts
you up. You want to return to class. You feel
good when you leave class. Its informative and
problem solving rather than problem nding.
(Participant #22, female, age 29)
Many participants believed that the program
taught skills that would be useful for other popu-
lations, such as schools, couples, and workplaces.
People clearly recognized the applicability of
happiness skills, and the openness to recommend-
ing the program to others suggested that there was
little stigma to attending the group. Furthermore,
the benets of being happier were evident across
participant responses (eg, got a job, spent more
time with children, felt better physically). The
universal appeal of happiness and a focus on the
positive and the future appeared to be important.
When participants were asked participants if they
would recommend the program and a positive
psychological approach to others, and why,
responses included the following:
Absolutely. This should bea mandatory Grade 12
class to learn skills for lifetime happiness and
coping. These skills need to be learned early in
life. (Participant #3, female, age 49).
The elderly need this as well. Its a phenomenon
how people turn negative when they get older,
and this would be very good to change their
perspective on life. Take it to care facilities for
old folks. People dont need to be negative when
they get old. (Participant #24, male, age 55)
Its hard to put on a happiness face when you are
feeling down. It gets harder and harder to be
someone that you arent. I just started to stay
home and not go out. Its too hard to be happy,
and you dont want people seeing you sad. Now
I have started to go out. I started to feel so much
better, and I went out and got a job. I needed to
get out, as the walls were talking back to me in
the house. This group was the positive change
I needed. Amen! (Participant #20, female, age 44)
The mind frame has become important to me,
and I have made an effort to get off the couch to
play with the kids. Making this effort gets easier
all the time. I am having fun. (Participant #19,
male, age 53)
I now have a desire to get up in morning, shower,
and get dressed even if Im not going anywhere.
This is a new habit for me. I need to appreciate
each day. (Participant #4, male, age 20).
I liked the fact that the class wasnt targeted
entirely to clinical depression if you are just
down, you could benet from this class. Just
come to learn and apply a different perspective.
This is a course that applies to everyone!
(Participant #8, female, age 51)
Discussion and conclusions
The results of the happiness intervention showed
that for the subset of patients who remained in
the program for six weeks and participated in
follow-up assessments, the repeated use of PPIs
was associated with decreased depression and
perceptions of pain and increased social function-
ing, subjective vitality, and overall mental health
over time. The most notable improvements on
indicators of the SF12v2
®
occurred over the course
of the initial study. All signicant improvements
were sustained during the follow-up period. The
effects of mental health on daily activities continued
to improve after the end of the study session, perhaps
reecting positive feedback loops as individuals
interacted with their environments from a founda-
tion of improved affect.
The ndings were consistent with results from
previous studies (eg, Duckworth et al., 2005; Seligman
et al., 2005; 2006; Sin and Lyubomirsky, 2009;
Lyubomirsky et al., 2011; Mongrain and Anselmo-
122 Louise T. Lambert Draven, Nina Moliver and Donna Thompson
Primary Health Care Research & Development 2015; 16: 114126
Matthews, 2012). Verbal responses also reected
physical, mental, and social improvements such as
obtaining employment, resisting a cold, enjoying
work more, spending more time with children
and spouses, being grateful for every day, and
expecting and planning for a bright future.
Several limitations may have affected the nd-
ings of this study. The attrition rate from baseline
to follow-up was high. One hundred and twenty-
four patients participated in the study initially and
75 remained at the end of the program. Further
attrition resulted in 36 participants responding to
follow-up assessment at three months, and 35 at
the nal assessment mark. Individuals whose well-
being did not improve from the intervention may
have left the program. Conversely, individuals who
remained in the program may have been highly
motivated, receptive, or committed to the style of
intervention. Other participants may not have
perceived the need to continue with the follow-up
measures, while others were unavailable (ie, moved
away, change in contact information, etc.). Thus,
conclusions can be drawn only on the subset of self-
selected individuals who remained in the program,
and the results of this study cannot be generalized
to other primary health care patients. Instead, the
results have shown that a PPI may be considered as
apotentiallybenecial intervention in alleviating
depression among a selected subset of primary
health care patients who, for undetermined reasons,
may be well suited to the effects of a PPI.
There was no control group to assess whether
positive changes in affect were attributable to the
intervention. The gains discovered in the study
may have been attributable to the passage of time.
All participants expected to feel happier and less
depressed through their participation in the pro-
gram. The expectation of feeling happier may have
functioned as a placebo and contributed to initial
gains. Gains may also have been attributable to
nonspecic factors such as the support of group
leaders, participation in the groups themselves, or
the benets from the social event held before the
nal follow-up evaluations. The presentation of
empirical literature may have had a persuasive
effect on the participants as the mere expectation
that PPIs will work has been shown to increase
their efcacy (Boehm and Lyubomirsky, 2009;
Sin and Lyubomirsky, 2009; Sheldon et al., 2010;
Lyubomirsky et al., 2011). Some patients were
receiving pharmaceutical treatment during the
program and these benets were not accounted
for. The Hawthorne effect, according to which
individuals improve their behavior when they
know they are being studied, may also explain
some of the ndings.
The self-selection of some participants may
also have contributed to an initial placebo effect,
as has been noted for many PPIs (Lyubomirsky
et al., 2011). However, most positive indicators
were maintained or improved at follow-up indi-
cating that a placebo effect was not an adequate
explanation for all improvements. Finally, as parti-
cipants are often eager to share their positive
improvements, the self-reports may have been
positively biased. We minimized this risk by enlist-
ing an independent interviewer for the focus groups.
Of note, self-reports are generally assumed to be
valid for positive as well as for negative experiences
(Peterson, 2006; Baumeister et al., 2007; Park and
Peterson, 2009).
The current study was a pilot study. The data
does not permit denitive conclusions to be drawn
regarding the benets of PPIs in a primary health
care setting, because of both the absence of a
control group and the high rate of attrition.
Follow-up studies are recommended with a control
group to assess whether improvements in well-
being can be attributed to the intervention, or
other moderating factors such as anti-depressant
medication, the passage of time, or participant
expectations. In future research, data should
be analyzed to determine reasons that patients
withdraw from a PPI or choose not to participate
in follow-up assessments.
PPIs have not been used widely in primary health
care and this intervention represents an initial
foray into the eld. By targeting primary health
care patients, this low-cost, non-stigmatizing and
brief pilot intervention was oriented equally to the
treatment of mental distress and to the preven-
tion and promotion of positive mental health. The
reduction of physical symptoms of pain through
PPIs may further help to reduce the health care
costs and dependency associated with depression
and its treatment, as well as the costs associated
with poorer functioning and time lost from pro-
ductive work. Using PPIs in a primary health care
setting may lead to new applications and future
research designed to improve health and function-
ing in both the physical and mental domains. A
focus on the positive may be the most powerful
Happiness program boosts happiness decreases pain 123
Primary Health Care Research & Development 2015; 16: 114126
medicine in increasing levels of well-being and in
providing participants with the skills to help them
manage themselves.
Acknowledgments
Thank you to the Red Deer Primary Care Network.
Financial Support
This research received no specic grant from any
funding agency, commercial, or not-for-prot sectors.
Conicts of Interest
None.
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... Seligman [48] also provided empirical evidence to highlight the conceptual difference between life satisfaction and happiness. Some researchers further explored the differences between life satisfaction and happiness through the effects from other factors such as positive mental health [49][50][51]. ...
... Empirical research typically indicates the antagonistic relation between life satisfaction and negative mental feelings [75,76]. In this regard, this research lends support to the call for a more focused approach to life satisfaction and happiness with a clear understanding of the effects of positive mental health [49][50][51]. ...
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... It is known that positive mood, life satisfaction, and happiness have an important role in preventing the development of mental disorders. It is also stated that these concepts both positively affect each other and are closely related to spiritual healing (Demirci et al., 2017;Lambert D'raven et al., 2015). Individuals with high levels of happiness are more likely to be more optimistic, more resistant to adverse environmental conditions, and more likely to develop effective coping skills to manage the stressful situation (Afshari et al., 2018;Tejada-Gallardo et al., 2020). ...
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This study aimed to determine the effects of the events during the COVID-19 epidemic on adolescents' levels of intolerance of uncertainty, internet addiction, happiness, and life satisfaction. Structural Equation Modeling was used in the analysis of the data. Adolescents' internet use increased during the epidemic process. It was found that COVID-19 events increased intolerance of uncertainty, and negatively affected internet addiction and happiness (p < 0.001). In this process, internet addiction and happiness is a mediator (p < 0.001). It is recommended to monitor adolescents' internet use during the COVID-19 process and to provide information about COVID-19.
... Scholars and experts are asking for new health interventions to support individuals' mental well-being [10]. Existing well-being interventions generally target health behaviors, including nutrition, physical activity, deep breathing exercises, relaxation exercises, mindfulness, meditation, gratitude practices (e.g., letter writing, journaling, three good things) and goal setting [11][12][13][14][15][16][17][18]. In a previous review of 13 health interventions, eight claimed that their intervention was informed by theory; however, only four interventions specified the use of theory-based behavior-change methods, and only one intervention specified exactly how such behavior-change methods were mapped to the theory listed. ...
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Approximately 1 in 5 Australians experience a mental disorder every year, costing the Australian economy $56.7 billion per year; therefore, prevention and early intervention are urgently needed. This study reports the evaluation results of a social marketing pilot program that aimed to improve the well-being of young adults. The Elevate Self Growth program aimed to help participants perform various well-being behaviors, including screen time reduction, quality leisure activities, physical activity, physical relaxation, meditation and improved sleep habits. A multi-method evaluation was undertaken to assess Elevate Self Growth for the 19 program participants who paid to participate in the proof-of-concept program. Social Cognitive Theory was used in the program design and guided the evaluation. A descriptive assessment was performed to examine the proof-of-concept program. Considerations were given to participants' levels of program progress, performance of well-being behaviors, improvements in well-being, and program user experience. Participants who had made progress in the proof-of-concept program indicated improved knowledge, skills, environmental support and well-being in line with intended program outcomes. Program participants recommended improvements to achieve additional progress in the program, which is strongly correlated with outcome changes observed. These improvements are recommended for the proof-of-concept well-being program prior to moving to a full randomized control trial. This paper presents the initial data arising from the first market offerings of a theoretically mapped proof-of-concept and reports insights that suggest promise for approaches that apply Social Cognitive Theory in well-being program design and implementation.
... Campaign/year/author/organisation Theory The Student Compass (Räsänen et al., 2016) Theories of learning, SCTa Gratitude Group Program (Wong et al., 2017) Positive psychology (no specific theory mentioned) Happiness 101 (Lambert D'raven et al., 2015) Positive psychology (no specific theory mentioned) HEYMAN (Ashton et al., 2017) SCT Internet-based mindfulness training program (Mak et al., 2015) Health behavioral theory An electronic wellness program to improve diet and exercise in college students (Schweitzer et al.., 2016) HBM; TRA; SCT; SLT; TTMb RCT of a smartphone-based mindfulness Intervention to enhance well-being (Howells et al., 2016) Positive Activity Model by Lyubomirsky and Layous (2013) The well-being game (Keeman et al., 2017) The broaden and build theory and mindfulness theory ...
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Purpose In social marketing practice, there is no all-encompassing approach that guides researchers and practitioners to build theory-driven social marketing interventions. While the Co-create–Build–Engage (CBE) process offers a roadmap for marketing application, including outlining when and where social marketing’s eight benchmark principles have been applied, limited practical guidance on how and when theory should be applied is offered. This paper reports one case study demonstrating how theory was applied to deliver a theory-informed well-being behavior change intervention. Design/methodology/approach This paper proposes and applies a new five-step theory-driven social marketing intervention build process (BUILD) drawn from an extensive base of social marketing research and application. Using a case study method, we showcase how the five-step process was applied to inform the design, build and implementation of a well-being behavior change intervention. Findings This study proposes a five-step process to build theory-driven social marketing interventions called BUILD: Begin with the objective, Use theory, Initiate program design, Let’s produce and Develop the engagement plan. This study provides a step-by-step and easy-to-follow BUILD process which outlines how social marketers can apply a selected theory to inform program design and implementation. Practical implications The BUILD process offers a roadmap to build theory-driven social marketing interventions that include all elements of intervention development, namely, objective-setting, theory evaluation, selection and application, producing the program and planning for program engagement. Originality/value This study provides a novel five-step process to help social marketing researchers and practitioners build theory-driven social marketing interventions.
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Background and objectives: The Best Possible Self (BPS) has been found to be an effective manipulation to temporarily improve optimism and affect. The BPS has been used in different formats. In some versions, participants just write about their best possible future, while in others this is combined with imagery. An imagery only version has not been tested yet. The aim of the current study was to examine the effectiveness of three different versions of the BPS and their equivalence in improving optimism and affect. Methods: In an online study format, participants (N = 141) were randomly assigned to one of four conditions: (1) writing and imagery BPS; (2) writing BPS; (3) imagery BPS; and (4) a typical day (TD) control condition. Results: Results showed that each BPS condition significantly improved optimism (i.e. increased positive future expectancies and decreased negative future expectancies) and affect (i.e. increased positive affect and decreased negative affect). Equivalence testing showed that all online BPS conditions were equivalent in increasing optimism and affect, thereby confirming that both the writing and imagery elements of the BPS can independently from each other increase optimism and positive affect in a healthy population. Limitations: Only the immediate effects of the BPS formats on increasing optimism and affect were measured. Conclusions: The BPS manipulation can be employed in different ways for potential future exploration, depending on the research question, design and context and/or E-mental health applications for the treatment of individuals suffering from psychological complaints.
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Objectives: There is a considerable debate regarding the possible dependence between depression and suicidal ideation treatments. The present study used a novel mediation approach in a randomized comparison of pharmacotherapy and combined therapy to explore whether depressive symptoms mediate the association between treatment and suicidal ideation and whether it depends on the treatment condition. Design: This study is a randomized, controlled, parallel group (1:1), clinical trial using a novel mediation approach for longitudinal data. Latent difference score modelling was utilized to investigate whether changes in depressive symptoms drive subsequent changes in suicide ideation. Method: Participants were 94 depressive suicidal outpatients who were assessed regarding depressive symptoms and suicidal ideation over the course of an experiment (0-2-7 months). Direct and indirect associations between (change in) depressive symptoms and (change in) suicidal ideation were explored using Pearson's correlations and latent difference score model. Results: The results showed that depression treatment affects not only suicidal ideation directly but also its influence on suicidal ideation occurs via improvement in depressive symptoms. It was found a more significant effect of combining pharmacotherapy and PPT (in comparison with the pharmacotherapy alone) on the early and late improvements of suicidal ideation (Δ 0-2 and Δ 2-7) via the early improvement of depressive symptoms (Δ 0-2). Conclusions: The findings indicate that changes in depressive symptoms preceded changes in suicidal ideation. Our results highlighted that improving depressive symptoms could be a primary target in treating patients with depression experiencing suicidal thoughts.
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A call for diverse research approaches in positive psychology by the International Positive Psychology Association (2015) and the Journal of Positive Psychology(2017) challenged psychology researchers to consider methodology outside traditional quantitative methods. The purpose of this methodological review was to examine the use of mixed methods approaches in empirical studies in positive psychology. The review identified 56 positive psychology articles published between 2010 and 2019 that used a mixed methods approach. To our knowledge, this is the first review of mixed methods methodology in the field of positive psychology. The small number of published articles in that period indicate mixed methods is either not currently a widely used methodology in the field or it is being used without identifying terminology. Those studies using mixed methods often used positive psychology to inform an intervention in the quantitative strand and gathered interviews within the qualitative strand. Opportunities for growth for positive psychology researchers include interpreting data in mixed methods style and strengthening the identification of key features of the approach in the text.
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Implementing positive psychotherapy in various cultures is challenging. This study assessed the clinical outcomes of a positive psychotherapy protocol based on “belief in divine goodness”, using a multiple-baseline design. We used a modified form of Seligman’s protocol on three Iranian adults with subclinical depression. Four new techniques were also added to the protocol to enhance the concept of happiness and life satisfaction, based on the dominant religious culture in Iran. The participants showed lower levels of depression but higher happiness, life satisfaction, pleasure, engagement and meaning in their lives compared to their status at the baseline. The new protocol may have psychotherapeutic benefits for use in subjects with subclinical depression. Future studies with larger sample sizes are warranted to assess the true effects of this protocol compared to those achieved by standard positive psychotherapy.
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In this work, we explore the relationship between depression and manifestations of happiness in social media. While the majority of works surrounding depression focus on symptoms, psychological research shows that there is a strong link between seeking happiness and being diagnosed with depression. We make use of Positive-Unlabeled learning paradigm to automatically extract happy moments from social media posts of both controls and users diagnosed with depression, and qualitatively analyze them with linguistic tools such as LIWC and keyness information. We show that the life of depressed individuals is not always bleak, with positive events related to friends and family being more noteworthy to their lives compared to the more mundane happy events reported by control users.
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Empirical and anecdotal evidence for hedonic adaptation suggests that the joys of loves and triumphs and the sorrows of losses and humiliations fade with time. If people's goals are to increase or maintain well-being, then their objectives will diverge depending on whether their fortunes have turned for the better (which necessitates slowing down or thwarting adaptation) or for the worse (which calls for activating and accelerating it). In this chapter, I first introduce the construct of hedonic adaptation and its attendant complexities. Next, I review empirical evidence on how people adapt to circumstantial changes, and conjecture why the adaptation rate differs in response to favorable versus unfavorable life changes. I then discuss the relevance of examining adaptation to questions of how to enhance happiness (in the positive domain) and to facilitate coping (in the negative domain). Finally, I present a new dynamic theoretical model (developed with Sheldon) of the processes and mechanisms underlying hedonic adaptation. Drawing from the positive psychological literature, I propose ways that people can fashion self-practiced positive activities in the service of managing stress and bolstering well-being.
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The literature on agency neglects temporality; the literature on temporality neglects agency. This paper integrates these largely separate lines of research with the concept "time work," which is defined as individual or interpersonal efforts to create or suppress particular kinds of temporal experience. Semistructured, open-ended interviews were conducted with 398 subjects, who were asked to describe ways in which they engage in time work. Analytic induction yielded five themes: in descending order of prevalence, the subjects reported efforts to control or manipulate duration, frequency, sequence, timing, and allocation. The variety and prevalence of time work suggests the sovereignty of self-determination; for the most part, however, time work contributes to cultural reproduction.
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This chapter discusses the challenges faced by the field of positive psychology as it approaches its second decade of existence. Among these is the lack of clarity on which research topics constitute "positive psychology"; the one-sided focus on desirablesounding constructs and topics, with new, exotic terms like self-compassion or state cheerfulness proliferating; and researchers' failure to consider the yin and yang of positive and negative, the dialectical tension between stress and growth.
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In this article, the author describes a new theoretical perspective on positive emotions and situates this new perspective within the emerging field of positive psychology. The broaden-and-build theory posits that experiences of positive emotions broaden people's momentary thought-action repertoires, which in turn serves to build their enduring personal resources, ranging from physical and intellectual resources to social and psychological resources. Preliminary empirical evidence supporting the broaden-and-build theory is reviewed, and open empirical questions that remain to be tested are identified. The theory and findings suggest that the capacity to experience positive emotions may be a fundamental human strength central to the study of human flourishing.
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From ancient history to recent times, philosophers, writers, self-help gurus, and now scientists have taken up the challenge of how to foster greater happiness. This chapter discusses why some people are happier than others, focusing on the distinctive ways that happy and unhappy individuals construe themselves and others, respond to social comparisons, make decisions, and self-reflect. We suggest that, despite several barriers to increased well-being, less happy people can strive successfully to be happier by learning a variety of effortful strategies and practicing them with determination and commitment. The sustainable happiness model (Lyubomirsky, Sheldon, & Schkade, 2005) provides a theoretical framework for experimental intervention research on how to increase and maintain happiness. According to this model, three factors contribute to an individual's chronic happiness level – 1) the set point, 2) life circumstances, and 3) intentional activities, or effortful acts that are naturally variable and episodic. Such activities, which include committing acts of kindness, expressing gratitude or optimism, and savoring joyful life events, represent the most promising route to sustaining enhanced happiness. We describe a half dozen randomized controlled interventions testing the efficacy of each of these activities in raising and maintaining well-being, as well as the mediators and moderators underlying their effects. Future researchers must endeavor not only to learn which particular practices make people happier, but how and why they do so.