Stfm Ne Mental Health Promotion (Fmdrl)

Changing Health ThroughChanging Health ThroughMental Health PromotionMental Health Promotion

Paul J. Hershberger, Ph.D.Paul J. Hershberger, Ph.D.

Mental Health and Mental Health and Family MedicineFamily Medicine

““Mental health services are an essential Mental health services are an essential element of the health care services element of the health care services continuum. continuum. Promotion of mental healthPromotion of mental health and the diagnosis and treatment of and the diagnosis and treatment of mental illness in the individual and mental illness in the individual and family context are also integral family context are also integral components of family medicine.” (AAFP components of family medicine.” (AAFP position paper on mental health, 2001)position paper on mental health, 2001)

How does a family physician promote How does a family physician promote mental health?mental health?

What is mental health?What is mental health?

Absence of mental illness?Absence of mental illness? National Institute of Mental HealthNational Institute of Mental Health

– Funds research of mental illnessFunds research of mental illness

Descriptions of Mental Descriptions of Mental HealthHealth

Freud – ability to love and to work; Freud – ability to love and to work; mature defense mechanismsmature defense mechanisms

Erikson – successful resolution of Erikson – successful resolution of psychosocial challengespsychosocial challenges

Maslow – self-actualizationMaslow – self-actualization


Marie Johada (Current Concepts of Marie Johada (Current Concepts of Positive Mental Health, 1958)Positive Mental Health, 1958)– Acceptance of oneselfAcceptance of oneself– Accurate perception of realityAccurate perception of reality– Autonomy (freedom from social pressures)Autonomy (freedom from social pressures)– Environmental masteryEnvironmental mastery– Growth, development, becomingGrowth, development, becoming– Integration of personalityIntegration of personality


Above normalAbove normal ResilienceResilience MaturityMaturity FlourishingFlourishing

FlourishingFlourishing

Mental health is more than the absence Mental health is more than the absence of mental illnessof mental illness

Languishing vs flourishingLanguishing vs flourishing Correlation of mental illness and mental Correlation of mental illness and mental

health: approx -.53health: approx -.53

Keyes CLM, Amer Psychol, Feb/Mar 2007

Dimensions of Mental Dimensions of Mental Health as FlourishingHealth as Flourishing

Positive affectPositive affect Avowed quality Avowed quality

of lifeof life Self-acceptanceSelf-acceptance Personal growthPersonal growth Purpose in lifePurpose in life Environmental Environmental

masterymastery AutonomyAutonomy

Positive relations Positive relations with otherswith others

Social acceptanceSocial acceptance Social Social

actualizationactualization Social Social

contributioncontribution Social coherenceSocial coherence Social integrationSocial integration


Mental health and mental Mental health and mental illness: prevalenceillness: prevalence


Mental illness and languishingMental illness and languishing 7.0%7.0%

Mental illness and moderately Mental illness and moderately mentally healthymentally healthy

14.5%14.5%

Mental illness and flourishingMental illness and flourishing 1.5%1.5%

Languishing (no MI)Languishing (no MI) 9.5%9.5%

Moderately mentally healthy (no Moderately mentally healthy (no MI)MI)

50.8%50.8%

Flourishing (no MI)Flourishing (no MI) 16.8%16.8%

Benefits of FlourishingBenefits of Flourishing

Better mental healthBetter mental health Better physical healthBetter physical health Better functioning (work)Better functioning (work)


Better Physical Health?Better Physical Health?

Positive emotion/optimismPositive emotion/optimism AgingAging BehaviorBehavior

The Nun StudyThe Nun Study

180 Catholic nuns; autobiographies written 180 Catholic nuns; autobiographies written between ages 18-32 (1931-1943) were scored between ages 18-32 (1931-1943) were scored for emotional contentfor emotional content

Age and educational attainment adjusted in Age and educational attainment adjusted in analysesanalyses

Emotional content related to survival at ages Emotional content related to survival at ages 75-9575-95

Positive emotional content associated with Positive emotional content associated with stepwise decrease in mortality (2.5 fold stepwise decrease in mortality (2.5 fold difference between lowest and highest difference between lowest and highest quartiles)quartiles)

Danner et al., JPSP, 80, 2001.

Mean age of death by number of Mean age of death by number of positive emotion sentences in positive emotion sentences in

autobiography:autobiography:

11stst (lowest) quartile: (lowest) quartile: 86.686.6 22ndnd quartile: quartile: 86.886.8 33rdrd quartile: quartile: 90.090.0 44thth (highest) quartile: (highest) quartile: 93.593.5

Danner et al., JPSP, 80, 2001

Attitudes Toward AgingAttitudes Toward Aging(Levy et al., 2002)(Levy et al., 2002)

Ohio Longitudinal Study of Aging and Ohio Longitudinal Study of Aging and Retirement (Miami U.)Retirement (Miami U.)

1,157 persons enrolled (age range 50-94) in 1,157 persons enrolled (age range 50-94) in 19751975

Attitudes toward aging measured with Attitudes toward aging measured with following items:following items:– Things keep getting worse as I get older.Things keep getting worse as I get older.– I have as much pep as I did last year.I have as much pep as I did last year.– I am as happy now as I was when I was younger.I am as happy now as I was when I was younger.– As you get older, you are less useful.As you get older, you are less useful.– As I get older, things are (better, worse, or the same) as I As I get older, things are (better, worse, or the same) as I

thought they would be.thought they would be.

Attitudes Toward AgingAttitudes Toward Aging(Levy et al., 2002)(Levy et al., 2002)

Data from 660 participants analyzed (specific Data from 660 participants analyzed (specific criteria met)criteria met)

As of 1/1/98, those with positive attitudes As of 1/1/98, those with positive attitudes toward aging at baseline lived 7.6 years toward aging at baseline lived 7.6 years longer than those with more negative longer than those with more negative attitudes toward agingattitudes toward aging

Order of variables re: impact on survival –Order of variables re: impact on survival –– Age, self-perceptions of aging, gender, loneliness, Age, self-perceptions of aging, gender, loneliness,

functional health, socioeconomic statusfunctional health, socioeconomic status

Positive AttitudesPositive Attitudes Toward Aging Toward Aging

Older adults tend to be happier than Older adults tend to be happier than young adultsyoung adults

Most older adults are not lonelyMost older adults are not lonely Most older adults adapt successfully to Most older adults adapt successfully to

physical difficulties that may occurphysical difficulties that may occur Continuing to use capabilities (physical Continuing to use capabilities (physical

and cognitive) is associated with less and cognitive) is associated with less decline in these abilitiesdecline in these abilities

Happiness-Health LinkHappiness-Health Link

Life satisfaction and happiness Life satisfaction and happiness contributes to mental health contributes to mental health

Better Better mental healthmental health (resilience, (resilience, coping effectiveness, relationship coping effectiveness, relationship quality, etc.) tends to be associated quality, etc.) tends to be associated with better physical healthwith better physical health

BehaviorBehavior

Benefits of HappinessBenefits of Happiness

Quality of LifeQuality of Life Better Health (mental and physical)Better Health (mental and physical) Cognitive Function (“broaden & build”; Cognitive Function (“broaden & build”;

creativity; increased speed and accuracy in creativity; increased speed and accuracy in diagnoses)diagnoses)

Resilience; builds abiding resources Resilience; builds abiding resources (intellectual, social, emotional, physical)(intellectual, social, emotional, physical)

Job SatisfactionJob Satisfaction Increased self-control?Increased self-control?

Correlates of HappinessCorrelates of Happiness

Small (</= .2)Small (</= .2) Moderate Moderate (~.3)(~.3)

Large (>/= .5)Large (>/= .5)

AgeAge Number of friendsNumber of friends GratitudeGratitude

GenderGender Being marriedBeing married OptimismOptimism

EducationEducation ReligiousnessReligiousness Being employedBeing employed

Social ClassSocial Class Level of leisure Level of leisure activityactivity

Self-esteemSelf-esteem

IncomeIncome Physical healthPhysical health Positive affect %Positive affect %

Having childrenHaving children ConscientiousnessConscientiousness Frequency of sexFrequency of sex

EthnicityEthnicity ExtraversionExtraversion Test-retestTest-retest

IntelligenceIntelligence Neuroticism (neg Neuroticism (neg corr.)corr.)

Inden. twin Inden. twin happinesshappiness

Physical Physical attractivenessattractiveness

Internal LOCInternal LOC

Correlates of HappinessCorrelates of Happiness

Correlation does not mean causationCorrelation does not mean causation Overlap in some factorsOverlap in some factors 33rdrd variable may be responsible for variable may be responsible for

correlationcorrelation In many areas, laboratory and/or In many areas, laboratory and/or

naturalistic studies suggest causative naturalistic studies suggest causative directiondirection

Happiness FormulaHappiness Formula

H = S + C + VH = S + C + V HHappinessappiness SSet range (genetics)et range (genetics) CCircumstances in lifeircumstances in life VVoluntary controloluntary control Positive psychology is primarily about Positive psychology is primarily about

the “V”the “V”

Sources of HappinessSources of Happiness

Positive EmotionPositive Emotion EngagementEngagement Meaning/PurposeMeaning/Purpose Victory?Victory?

VIA Classification of VIA Classification of StrengthsStrengths

(24 Character Strengths)(24 Character Strengths) ““unDSM”unDSM” Widely recognized Widely recognized

across culturesacross cultures FulfillingFulfilling Valued in their own Valued in their own

rightright Behavioral display Behavioral display

(expressing the (expressing the strengths) does not strengths) does not diminish othersdiminish others

Trait-like (part of Trait-like (part of who you are)who you are)

MeasurableMeasurable

VIA Classification of VIA Classification of StrengthsStrengths

(24 Character Strengths)(24 Character Strengths) Ubiquitous (widely Ubiquitous (widely

recognized across recognized across religions/culture)religions/culture)

MeasurableMeasurable Paragons/prodigiesParagons/prodigies

Wisdom and KnowledgeWisdom and Knowledge(cognitive strengths that involve the (cognitive strengths that involve the

acquisition and use of knowledge)acquisition and use of knowledge)

Creativity (originality, ingenuity)Creativity (originality, ingenuity) Curiosity (interest, openness to Curiosity (interest, openness to

experience)experience) Open-Mindedness (includes Open-Mindedness (includes

judgment, critical thinking)judgment, critical thinking) Love of learning (adding to what one Love of learning (adding to what one

knows)knows) Perspective (wisdom; seeing the Perspective (wisdom; seeing the

world in ways that make sense to world in ways that make sense to self and others)self and others)

CourageCourage(emotional strengths that involve the (emotional strengths that involve the

exercise of will to accomplish goals in spite exercise of will to accomplish goals in spite of opposition)of opposition)

Bravery (valor)Bravery (valor) Persistence (perseverance, Persistence (perseverance,

industriousness)industriousness) Integrity (authenticity, honesty)Integrity (authenticity, honesty) Vitality (zest, enthusiasm; approaching Vitality (zest, enthusiasm; approaching

life with excitement and energy)life with excitement and energy)

HumanityHumanity(interpersonal strengths that involve (interpersonal strengths that involve “tending” and “befriending” others)“tending” and “befriending” others)

Love (capacity to love and be loved)Love (capacity to love and be loved) Kindness (generosity, nurturance, Kindness (generosity, nurturance,

care, compassion)care, compassion) Social Intelligence (emotional Social Intelligence (emotional

intelligence, personal intelligence)intelligence, personal intelligence)

JusticeJustice(civic strengths that support (civic strengths that support

community life)community life)

Citizenship (social responsibility, Citizenship (social responsibility, loyalty, teamwork)loyalty, teamwork)

Fairness/EquityFairness/Equity LeadershipLeadership

TemperanceTemperance(strengths that protect against excess)(strengths that protect against excess)

Forgiveness and MercyForgiveness and Mercy Humility and ModestyHumility and Modesty Prudence/CautionPrudence/Caution Self-Regulation (self-control, self-Self-Regulation (self-control, self-

discipline)discipline)

TranscendenceTranscendence(strengths that forge connections to the larger (strengths that forge connections to the larger

universe and provide meaning)universe and provide meaning)

Appreciation of Beauty and Excellence Appreciation of Beauty and Excellence (awe, wonder)(awe, wonder)

GratitudeGratitude Hope (optimism, future-mindedness)Hope (optimism, future-mindedness) Humor (playfulness)Humor (playfulness) Spirituality (faith, purpose, Spirituality (faith, purpose,

religiousness)religiousness)

Strengths ResearchStrengths Research

Strengths most related to life Strengths most related to life satisfaction are: love, vitality, hope, satisfaction are: love, vitality, hope, and gratitudeand gratitude

Most endorsed strengths (worldwide)Most endorsed strengths (worldwide)– Kindness, fairness, authenticity, Kindness, fairness, authenticity,

gratitude, open-mindednessgratitude, open-mindedness Least endorsed strengthsLeast endorsed strengths

– Prudence, modesty, self-regulationPrudence, modesty, self-regulation

Developing StrengthsDeveloping Strengths

To develop strengths:To develop strengths:– Increase awareness (identify, name, Increase awareness (identify, name,

think about)think about)– Practice, practice, practice (in social Practice, practice, practice (in social

context)context)– Self-monitor (keep a journal of your Self-monitor (keep a journal of your

practice)practice) Examples for specific strengthsExamples for specific strengths

VIA-ISVIA-IS

www.authentichappiness.sas.upenn.eduwww.authentichappiness.sas.upenn.edu www.viastrengths.orgwww.viastrengths.org

Positivity/Negativity in Positivity/Negativity in RelationshipsRelationships

POSITIVEPOSITIVE SupportSupport EncouragementEncouragement AppreciationAppreciation

NEGATIVENEGATIVE DisapprovalDisapproval SarcasmSarcasm CynicismCynicism

Positivity/Negativity RatiosPositivity/Negativity Ratios

For a marriage to flourish… 5:1For a marriage to flourish… 5:1 For a workplace team to flourish For a workplace team to flourish

(productivity, customer (productivity, customer satisfaction, employee ratings)… satisfaction, employee ratings)… 3:13:1

Upper limit… 13:1Upper limit… 13:1– Negative feedback is critical for Negative feedback is critical for

realism, correction, and adjustments.realism, correction, and adjustments.

Interventions to promote Interventions to promote life satisfaction and mental life satisfaction and mental

healthhealth

Positive emotions re: past, present, Positive emotions re: past, present, futurefuture

Fostering “flow”Fostering “flow” Enhancing meaningEnhancing meaning MiscellaneousMiscellaneous

Brief Interventions toBrief Interventions toPromote Mental HealthPromote Mental Health

QuestionsQuestions Change of mindset/perspectiveChange of mindset/perspective Change in behaviorChange in behavior Improvement in relationshipsImprovement in relationships Model for patientModel for patient

Positive Emotions: PastPositive Emotions: Past

1) “What is something you are thankful 1) “What is something you are thankful for in your life?”for in your life?”

2) “For one week, each night write down 2) “For one week, each night write down three things for which you are thankful.”three things for which you are thankful.”

3) “Think of someone whom you have 3) “Think of someone whom you have not properly thanked for something not properly thanked for something good they’ve done for you. Write that good they’ve done for you. Write that person a thank you letter. (Make an person a thank you letter. (Make an appointment with that individual, if appointment with that individual, if possible, and read your letter to her/him possible, and read your letter to her/him in person, or send it.)”in person, or send it.)”

Positive Emotions: PresentPositive Emotions: Present

4) “How are you well today?”4) “How are you well today?” 5) “Describe something that is going 5) “Describe something that is going

very well in your life.”very well in your life.” 6) “What is something that you enjoy 6) “What is something that you enjoy

that you could spend more time that you could spend more time doing?” (longcuts instead of shortcuts)doing?” (longcuts instead of shortcuts)

Positive Emotions: PresentPositive Emotions: Present

7) “What is something you enjoy 7) “What is something you enjoy that you could set aside some time that you could set aside some time to do, just for enjoyment?”to do, just for enjoyment?”– Enhance savoring by:Enhance savoring by:

Sharing the experience with others (or tell Sharing the experience with others (or tell others about it)others about it)

Attend to details of the activity/experience Attend to details of the activity/experience utilizing as many senses as possibleutilizing as many senses as possible

Take mental photographs (or physical Take mental photographs (or physical souvenirs) and reminisce later with otherssouvenirs) and reminisce later with others

Positive Emotions: FuturePositive Emotions: Future

8) “Tell me about an experience in your 8) “Tell me about an experience in your life in which some door closed on you, life in which some door closed on you, but you later found another door that but you later found another door that opened for you.”opened for you.”

Positive Emotions: FuturePositive Emotions: Future

9) Book Recommendations (higher 9) Book Recommendations (higher functioning patients)functioning patients)– Learned OptimismLearned Optimism, Martin Seligman, Martin Seligman– The Resilience FactorThe Resilience Factor, Karen Reivich & , Karen Reivich &

Andrew ShatteAndrew Shatte

Increasing “Flow”Increasing “Flow”

10) “What is one of the best parts of 10) “What is one of the best parts of your personality?” “How can you use your personality?” “How can you use that characteristic even more in your that characteristic even more in your life?”life?”

11) Identify a “signature strength” that 11) Identify a “signature strength” that you can use in a new way.you can use in a new way.– www.viastrengths.orgwww.viastrengths.org

List of 24 strengthsList of 24 strengths VIA-IS (inventory, 30 minutes to complete)VIA-IS (inventory, 30 minutes to complete)

Increasing “Flow”Increasing “Flow”

12) “How can you think about your 12) “How can you think about your work/job as a way to express one (or work/job as a way to express one (or more) of your “signature strengths?”more) of your “signature strengths?”

13) “What’s an activity that you can 13) “What’s an activity that you can become so absorbed with that you aren’t become so absorbed with that you aren’t even aware of time?” “How can you even aware of time?” “How can you protect blocks of time to spend time with protect blocks of time to spend time with that activity?”that activity?”

14) “What is something particularly kind 14) “What is something particularly kind that you could do for someone you know?”that you could do for someone you know?”

MiscellaneousMiscellaneous

15) “What particular relationship in 15) “What particular relationship in your life is a place where you could be your life is a place where you could be more supportive/encouraging with the more supportive/encouraging with the other person?” (Increase the ratio of other person?” (Increase the ratio of positive/negative interactions.)positive/negative interactions.)– Increase use of supportive, complimentary, Increase use of supportive, complimentary,

and kind comments.and kind comments.– Decrease use of sarcasm, disapproval, Decrease use of sarcasm, disapproval,

denigration.denigration.

MiscellaneousMiscellaneous

16) “When something good 16) “When something good happens in your life, make sure you happens in your life, make sure you tell one or more other people in tell one or more other people in your life about the good thing.”your life about the good thing.”

17) “When someone shares good 17) “When someone shares good news with you, enthusiastically tell news with you, enthusiastically tell that person how happen you are for that person how happen you are for her/him. Ask the person to tell you her/him. Ask the person to tell you even more about the good news.”even more about the good news.”

Internet ResearchInternet Research

5 Positive Psychology Interventions & 5 Positive Psychology Interventions & 1 Control1 Control– ““Three good things” exercise (gratitude)Three good things” exercise (gratitude)– Gratitude visitGratitude visit– Taking VIA Strengths Inventory and Taking VIA Strengths Inventory and

receiving feedbackreceiving feedback– Using your strengthsUsing your strengths– ““You at your best” storyYou at your best” story– Control: write about earliest memories Control: write about earliest memories

each night for one weekeach night for one week

Internet Research: ResultsInternet Research: Results

All groups happier at immediate post All groups happier at immediate post test (end of week-long intervention)test (end of week-long intervention)

One week later: control, taking One week later: control, taking strengths inventory, and “you at your strengths inventory, and “you at your best” groups were back to baselinebest” groups were back to baseline

Internet Research: ResultsInternet Research: Results

Gratitude visit group: happier for one Gratitude visit group: happier for one month but return to depressive month but return to depressive symptoms by one monthsymptoms by one month

““Using your strengths” and “three Using your strengths” and “three good things” groups were happier and good things” groups were happier and less depressed at one, three, and six-less depressed at one, three, and six-month follow-up intervalsmonth follow-up intervals

ConclusionsConclusions

Mental health promotion is part of the Mental health promotion is part of the domain of family medicine.domain of family medicine.

Mental Mental healthhealth contributes to better contributes to better physical health.physical health.

Strategies to promote life satisfaction Strategies to promote life satisfaction and happiness can be used for mental and happiness can be used for mental health promotion.health promotion.

ReferencesReferences

Danner DD et al. Positive emotions in early life Danner DD et al. Positive emotions in early life and longevity: Findings from the Nun Study. J and longevity: Findings from the Nun Study. J Pers Soc Psychol 2001;80:804-813.Pers Soc Psychol 2001;80:804-813.

Fredrickson BL, Losada MF. Positive affect and Fredrickson BL, Losada MF. Positive affect and the complex dynamics of human flourishing. the complex dynamics of human flourishing. Amer Psychol 2005;60:678-686.Amer Psychol 2005;60:678-686.

Gable SL et al. What do you do when things go Gable SL et al. What do you do when things go right? The intrapersonal and interpersonal right? The intrapersonal and interpersonal benefits of sharing positive events. J Pers Soc benefits of sharing positive events. J Pers Soc Psychol 2004;87:228-245.Psychol 2004;87:228-245.

Gilbert D. Stumbling on Happiness. 2006.Gilbert D. Stumbling on Happiness. 2006.

References (cont.)References (cont.)

Haidt J. The Happiness Hypothesis. 2006.Haidt J. The Happiness Hypothesis. 2006. Hershberger PJ. Prescribing happiness: Positive Hershberger PJ. Prescribing happiness: Positive

psychology and family medicine. Fam Med psychology and family medicine. Fam Med 2005;37:630-634.2005;37:630-634.

Keyes, CLM. Promoting and protecting mental Keyes, CLM. Promoting and protecting mental health as flourishing. Amer Psychol health as flourishing. Amer Psychol 2007;62:95-108.2007;62:95-108.

Levy BR, Slade MD, Kunkel SR, Kasl SV. Levy BR, Slade MD, Kunkel SR, Kasl SV. Longevity increased by positive self-Longevity increased by positive self-perceptions of aging. J Pers Soc Psychol perceptions of aging. J Pers Soc Psychol 2002;83:261-270.2002;83:261-270.

Peterson C. A Primer in Positive Psychology. Peterson C. A Primer in Positive Psychology. 2006.2006.

References (cont.)References (cont.)

Peterson C & Seligman MEP. Character Peterson C & Seligman MEP. Character Strengths and Virtues: A Handbook and Strengths and Virtues: A Handbook and Classification. 2004.Classification. 2004.

Reivich K & Shatte A. The Resilience Factor. Reivich K & Shatte A. The Resilience Factor. 2002.2002.

Schwartz B. The Paradox of Choice: Why More is Schwartz B. The Paradox of Choice: Why More is Less. 2004.Less. 2004.

Seligman MEP. Authentic Happiness. 2002.Seligman MEP. Authentic Happiness. 2002. Seligman MEP. Learned Optimism. 1998.Seligman MEP. Learned Optimism. 1998. Snyder CR & Lopez SJ (eds). Handbook of Snyder CR & Lopez SJ (eds). Handbook of

Positive Psychology. 2002.Positive Psychology. 2002. www.authentichappiness.sas.upenn.eduwww.authentichappiness.sas.upenn.edu www.ppc.sas.upenn.eduwww.ppc.sas.upenn.edu www.viastrengths.orgwww.viastrengths.org

Paul J. Hershberger, Ph.D., ABPP

Professor, Department of Family Medicine

Director of Behavioral Science,

Dayton Community Family Medicine Residency Program

Wright State University Boonshoft School of Medicine

2345 Philadelphia Drive

Dayton, OH 45406

937-278-6251, ext 2021

FAX: 937-277-7249

[email protected]

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