Lecture 9: Quality of Life and Positive Psychology (Health Psychology)

A. Quality of Life - Definition and Scope

• Quality of Life (QoL) means how good someone's life is, considering many areas like:
  • How well their body works (Physical functioning)
  • Their emotional and mental state (Psychological status)
  • How well they interact with others (Social functioning)
  • Symptoms from illness or treatment
  • How much their daily activities are affected (Interference with activities of daily living - ADL)
• Components and ADL Examples (as used in QoL assessments):
  • Washing: Being able to wash oneself, including getting in and out of a bath or shower.
  • Dressing: Being able to put on and take off all clothes and any medical devices.
  • Feeding: Being able to eat prepared food by oneself.
  • Toileting: Being able to use the toilet or manage bladder/bowel functions.
  • Mobility: Being able to move around indoors on flat surfaces.
  • Transferring: Being able to move from a bed to a chair, or vice versa.
• QoL and Chronic Health Problems: Emotional Issues:
  • Denial: When patients (e.g., heart, stroke, cancer) refuse to believe their illness is happening. It can be helpful short-term but harmful if overused.
  • Anxiety: Worry and fear, often triggered by life changes or thoughts of death, which can make it hard to function.
  • Depression: Very common in later stages of illness, can come and go, and can make other health problems worse. Getting treatment for it is important.
• The Four Aspects of the Self in Chronic Illness (Identity/Adjustment Framework):
  • The Physical self: How someone sees their body. Illness often makes body image worse, leading to lower self-esteem and more depression/anxiety. Body image usually improves except in severe cases like facial disfigurement.
  • The Achieving self: What a person accomplishes, which boosts self-esteem. This is important for a good QoL.
  • The Social self: How a person fits into social roles and relationships. Getting back to these roles is key after a chronic illness.
  • The Private self: How independent a person feels. Losing independence and relying more on others can be a big blow to self-identity.
• Why QoL Research Matters:
  • Shows how illness impacts daily life.
  • Helps predict problems patients with certain diseases might face.
  • Provides a way to check if treatments are working.
  • Offers a reference point to compare different therapies.
  • Helps decision-makers prioritize and deliver better care.

B. Management of Chronic Health Problems

• Chronic Health Problems: Examples and Focus - Coronary Heart Disease (CHD):
  • Definition: Illnesses caused by atherosclerosis, where fatty deposits build up inside the heart's arteries.
  • Plaque buildup makes arteries thicker and harder. This can cause:
  • Angina: Chest pain from a brief or partial blockage.
  • Myocardial Infarction: A heart attack from a severe or long-lasting blockage.
• CHD Risk Factors:
  • Demographic/Sociocultural:
  • Men and those over $45$ are at higher risk.
  • It's the top killer for women in the US after menopause.
  • People with lower socioeconomic status (SES) are at higher risk.
  • Lifestyle/Biological:
  • High blood pressure (hypertension), family history of heart disease, smoking.
  • High "bad" cholesterol (LDL) and total cholesterol, not being physically active, diabetes, obesity, stress, and inflammation in the body.
• Personality and Heart Disease:
  • Type A personality: People who are competitive, impatient, and easily angered tend to have stronger physical reactions to stress (like increased blood pressure).
  • Hostility, depression, anxiety, pessimism/rumination: These emotional states can increase heart disease risk through physical changes and how people cope.
• Stress and Heart Disease:
  • Frequent or long-term stress is linked to a higher risk of heart disease.
  • CHD is more common in people with low SES, job strain (high demands, low control), and unstable social lives (like moving a lot or changing jobs often).
• Rehabilitation of Cardiac Patients:
  • Goals: Reduce symptoms, slow the disease, help patients adjust, and restore their activities.
  • Components: Education about the disease, changing lifestyle, improving diet (e.g., managing cholesterol), stopping smoking (about $40\%$ quit successfully), doing aerobic exercise, and stress management (which can reduce deaths).
  • Treatment Adherence and Self-Efficacy: Helping patients regain a sense of control, improve their beliefs about their disorder, be more optimistic, and get social support. Cognitive Behavioral Therapy (CBT) can help with depression.
• Stroke: Overview and Rehabilitation:
  • Definition: Occurs when blood flow to the brain is blocked (Ischemic stroke) or when a blood vessel in the brain bleeds (Hemorrhagic stroke). This causes brain tissue to die.
  • Risk Factors: Age, gender, social/cultural factors, high blood pressure, smoking, heart disease, high cholesterol, diabetes, obesity, inactivity, heavy alcohol use, drug use, family history, previous mini-strokes (TIA), and negative emotions/psychological distress.
  • Effects: Depend on where in the brain the damage occurs.
  • Left brain damage: Often causes problems with thinking, memory, and language (aphasia).
  • Right brain damage: Can cause issues with visual perception and emotions.
  • Can also lead to movement problems and emotional/relationship difficulties.
  • Rehabilitative Interventions: Therapies to improve thinking skills, movement exercises, engaging environments that stimulate recovery, and support for caregivers.
• Diabetes Mellitus:
  • Definition: A long-term condition where the body has trouble processing carbohydrates, proteins, and fats because it doesn't make enough insulin or can't use insulin properly, leading to high blood sugar (hyperglycemia).
  • Type I (IDDM): About $10\%$ of cases; starts suddenly, usually in childhood/adolescence; the body's immune system destroys insulin-producing cells; requires insulin injections.
  • Type II (NIDDM): Usually starts after age $40$; body becomes resistant to insulin, sometimes with less insulin production; can affect overweight or normal-weight individuals.
  • Psychosocial Factors Influencing Course: Stress and the stress hormone cortisol can raise blood sugar. It's hard for people to stick to treatment plans because they are often complex and lifelong. Adjusting to diabetes is especially tough for children and teens due to family stress, frequent blood sugar checks, and injections, leading to lower compliance.
• Adapting to Chronic Illness and Prognosis:
  • Initially, fear of death is high. Activities can offer a break from worrying. Mentally, people try to find meaning, feel more in control, and regain self-esteem.
  • Adapting to recurrence/relapse (for high-mortality diseases): Relapses are another crisis, and coping becomes harder.
  • Terminal illness (high chance of death): Denial is a common first reaction. Better adjustment is linked to less pain, strong social support, and having coped well with past challenges.
  • Kübler-Ross stages (not experienced by everyone): Denial, Anger, Bargaining, Depression, Acceptance.
• Developmental Considerations for Terminal Illness:
  • Children under $5$ might not fully understand that death is permanent. By age $8$, most do.
  • Parents often hide information, but children usually sense how serious things are.
  • Teenagers may find untimely death more unfair and experience more anger/distress.
  • Adults might adjust more easily with age, as illness may seem less surprising. Those who have lived meaningful lives tend to adjust better.

C. Positive Psychology – An Overview

• PERMA Model (A framework for well-being):
  • Positive Emotion: Feeling good.
  • Engagement: Being fully absorbed in activities.
  • Relationships: Having strong, positive connections with others.
  • Meaning: Having a sense of purpose.
  • Accomplishment: Achieving goals.
• Do Positive Psychology Interventions Work?
  • Studies (like meta-analyses by Carr et al., 2021) show that these interventions generally have positive effects.
  • There's a trend of improvements in overall well-being and Quality of Life, though the effects vary.
  • Some studies also show reductions in negative feelings like depression, anxiety, and stress, with small to moderate improvements.
  • Typical effects (from Carr et al., $2021$ meta-analysis, where $g$ shows the size of the effect):
  • Wellbeing: $g \approx 0.30\text{ to }0.32$
  • QoL: $g \approx 0.32$
  • Depression: $g \approx -0.29$ (meaning reduction)
  • Anxiety: $g \approx -0.18$ (meaning reduction)
  • Stress: $g \approx -0.40$ (meaning reduction)
  • Overall: Interventions focusing on gratitude and positive psychology can improve many aspects of well-being, but results depend on what's being measured and how the study was done.
• Context on Gratitude Interventions: These are one type of positive psychology intervention that has been widely studied.

D. Gratitude

• Methods of Manipulating Gratitude:
  • Gratitude lists: Writing down things, people, or events you are grateful for over a period of time.
  • Journaling: Writing more detailed accounts of gratitude than just lists.
  • Interpersonal expressions: Expressing thanks to others, often through letters or direct communication.
• Gratitude Interventions – Critical Considerations:
  • Researchers like Wood et al. ($2010$) warned against over-enthusiasm because many studies used control groups that focused on negative things (e.g., listing hassles), which might make gratitude seem too good by comparison.
  • Davis et al. ($2016$) performed a meta-analysis comparing gratitude interventions to:
  • Measurement-only controls: Just measuring things without any intervention.
  • Active/alternative control groups: Doing another activity that's not gratitude-focused.
• Gratitude Interventions – Meta-Analytic Findings (Davis et al., 2016):
  • Compared to measurement-only controls: Gratitude interventions improved psychological well-being (effect size $d = 0.31$), but didn't strongly improve gratitude itself (effect size $d = 0.20$).
  • Compared to an alternative-activity control: Gratitude interventions improved gratitude (effect size $d = 0.46$) and psychological well-being (effect size $d = 0.17$), but didn't clearly reduce anxiety ($d = 0.11$).
• Using Gratitude to Promote Positive Change (Dickens, Northeastern Univ., $2017$):
  • A large review of $38$ studies found that while gratitude interventions can improve happiness, they don't always improve every outcome. The benefits might be exaggerated in some research.
  • Conclusion: Gratitude interventions have varied effects; they're not always "too good to be true," and their benefits can depend on the situation.
• Types of Gratitude Interventions – Differential Effects (Regan, Walsh, Lyubomirsky, $2022$):
  • Intervention formats: Short lists vs. detailed writing, thanking specific people vs. general things, letters vs. essays.
  • Key finding: Longer, more detailed writing (like gratitude letters) usually leads to greater improvements in well-being and positive emotions than short lists. Expressing gratitude to others can boost effects but might also make people feel obligated.
  • Medium matters: Saying thank you face-to-face, on the phone, or via text all improve well-being more than doing nothing. Face-to-face can sometimes feel more awkward.
  • Practical takeaway: Longer, more socially involved gratitude expressions often produce bigger benefits, even if social situations can be a bit new or uncomfortable.
• Why Gratitude Interventions May Not Always Be Perfect:
  • Their impact depends on the format, who else is involved, and individual differences.
  • What both the giver and receiver expect and interpret can change the outcome.
  • How effective a method (like a letter vs. a text) is might depend on people's communication habits and cultural norms.
• Mediums of Gratitude Expression ($2022$ findings):
  • Three ways of saying thank you were tested: face-to-face, phone, and text.
  • All three increased well-being compared to doing nothing. Face-to-face might feel more embarrassing or awkward in some situations.
• Overall Effectiveness (Summary Numbers):
  • Gratitude interventions generally improve well-being and QoL and can reduce negative feelings, but results vary based on the comparison group and what's being measured.
  • From Carr et al. ($2021$):
  • Wellbeing: $g \approx 0.30\text{ to }0.32$
  • Strengths: $g \approx 0.31$
  • QoL: $g \approx 0.32$
  • Depression: $g \approx -0.29$
  • Anxiety: $g \approx -0.18$
  • Stress: $g \approx -0.40$
• Key Takeaways for Practice:
  • Gratitude interventions can boost well-being and QoL, but it's important to consider the quality of the research and what the control group did.
  • Longer, more thoughtful writing and social expressions (like letters) may lead to greater benefits, though they might also feel a bit awkward or create feelings of debt.

E. Positive Psychology – Savoring

• What is Savoring?
  • It's a way of managing your emotions by intentionally increasing positive feelings (Quoidbach et al., $2010$).
  • Methods include:
  • Actively looking for positive situations.
  • Taking steps to make pleasant experiences even better.
  • Deliberately paying attention to the good parts of something.
  • Changing how you think about things (reappraisal) and how you react to them.
• Savoring Strategies (Emotion Regulation Profile-Revised, $8$-item):
  • Savoring Strategies ($4$ strategies):
  • Behavioral display: Showing positive emotions through body language.
  • Be present: Focusing your attention on the good experience happening right now.
  • Capitalizing: Sharing and celebrating positive events with others.
  • Positive mental time travel: Clearly remembering or imagining good things.
  • Dampening Strategies ($4$ strategies):
  • Suppression: Hiding positive emotions.
  • Distraction: Thinking about other things instead of the positive event.
  • Fault finding: Focusing on the negatives or what could be better.
  • Negative mental time travel: Dwelling on bad reasons for good events or expecting bad things to happen in the future.
• Experimental Findings and Examples:
  • A powerful idea: "There is a last time for everything" – thinking that something might be happening for the last time can make you appreciate it more deeply.
  • Ancient philosophy (like Stoicism) encourages focusing on the present, similar to mindful engagement.
  • Research on "temporal scarcity" (things being limited in time) shows it can significantly increase perceived happiness in some cases.
• Meta-Analytic Findings (Carr et al., 2021):
  • Wellbeing: $g = 0.77$
  • Strengths: $g = 0.42$
  • QoL: $g = 0.10$
  • Depression: $g = -0.70$
  • Anxiety: $g = -0.80$
• Do Savoring Interventions Work? Overall, research shows noticeable positive effects on well-being and reductions in depression and anxiety in some studies, but improvements in Quality of Life might be smaller.

F. Positive Psychology – Flow

• What is Flow?
  • It's a deeply enjoyable state of being completely absorbed in a task, with focused and undistracted attention. You feel like you're in control without effort; your actions and awareness merge; time seems to change, and the experience itself is rewarding.
  • It has been described with quotes about extreme focus and effortless action.
• Csikszentmihalyi’s Nine Dimensions of Flow:
  1. Challenge–skills balance: The task is challenging enough to be engaging but not so hard that you get frustrated.
  2. Merging of action and awareness: Your actions feel automatic, and you're not thinking about what you're doing, just doing it.
  3. Clear goals: You know exactly what you're trying to achieve.
  4. Unambiguous feedback: You immediately know if you're doing well.
  5. Concentration on the task at hand: You're completely focused on what you're doing.
  6. Sense of control: You feel in charge of the situation.
  7. Loss of self-consciousness: You stop worrying about yourself or how others see you.
  8. Transformation of time: Time seems to pass differently (either faster or slower).
  9. Autotelic experience: The activity is rewarding in itself; you do it for the pure joy of it.
• Flow: Framework and Outcomes (Summary from Norsworthy et al., $2021$):
  • Things that lead to flow (Antecedents & Experience): Personal traits like autonomy and curiosity, feeling excited, being present, taking risks, recovering well, trust, having an optimal challenge, clear goals, immediate feedback, complete absorption, feeling like action and awareness are one, effortless control, not worrying about losing control, and feeling capable.
  • Situational conditions for flow: Being highly motivated, having support for your independence, a safe environment, social/cultural support, the activity being its own reward, feeling good emotions, and feeling optimally excited.
  • Results of flow (Outcomes): Better well-being, improved mental health, less stress, positive personal growth, more creativity, better academic performance, greater cognitive efficiency, and faster skill learning.
  • Continuing to engage and stay motivated leads to more flow experiences and better overall functioning.
• Do Flow Interventions Work? It's not always clear if interventions designed to create flow consistently lead to improvements. The effectiveness can depend on the situation, the type of task, and individual differences.

G. Positive Psychology – Self-Efficacy

• Self-Efficacy Theory (Bandura, 1977):
  • Main Idea: If someone has the necessary skills and motivation, their belief in their ability to succeed at a specific task (self-efficacy) is the most important factor in how well they perform.
• Sources of Self-Efficacy (SET):
  • Past performance accomplishments (mastery experiences): Successfully completing similar tasks in the past increases your belief in your ability. The more similar the task, the stronger the effect.
  • Vicarious experiences (modeling): Watching others successfully complete a task can make you believe you can do it too, especially if the person you watch is similar to you.
  • Social persuasion: Encouragement (verbal or non-verbal) from others. This is most powerful when it comes from someone knowledgeable or important to you.
  • Physiological and affective states: Your physical feelings (like arousal) and mood can either boost or lower your perceived self-efficacy.
• Do Self-Efficacy Interventions Work?
  • Research (like Sheeran et al., $2016$) shows that interventions designed to