Health Psychology and Positive Psychology

Health psychology is the scientific study of the relations of psychological factors, behavior, and the social environment with physical health and illness. Accordingly, health psychologists often adhere to a biopsychosocial model of health to understand the multifactorial contributions of biological, psychological, and social factors to health and well-being. This “mind–body” model recognizes the dynamic impact on health from various biological (e.g., a tumor, virus), psychological (e.g., perceived stress, attitudes, behaviors), and social influences (e.g., socioeconomic status, culture, ethnicity; Ogden, 2012).

Much of the focus of health psychology is on the reciprocal association between stress and health. Health psychologists study both the impact of psychological stress on physical health and the extent to which living with a health condition is stressful. Given the central role that stress has within health psychology, it is important to first describe what we mean by stress and then highlight a number of the physical health sequelae of chronic stress. Stress is “a relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being” (Lazarus & Folkman, 1984, p. 19). The physiological response to perceived stress (i.e., “fight or flight”) is adaptive and accompanied by the release of epinephrine and norepinephrine, which increases cardiovascular responses (heart rate and blood pressure), respiration, perspiration, blood flow to active muscles, muscle strength, and mental activity. Perceptions of stress also activate cortisol release, which triggers protein and fat mobilization, increases access to energy storage, and decreases inflammation (Selye, 1956). Although this acute stress response serves important adaptive functions, chronic stress can result in negative physical effects and can negatively impact every major system in the body.

In response to the compelling evidence of the deleterious effects of stress on health, health psychologists have focused primarily on reducing negative affect and stress. However, there has been a shift from this negative-affect-only focus toward the potential unique effects of positive psychological states and traits. Although a number of researchers were doing significant work in positive domains prior to this (e.g., Isen & Shalker, 1982; Lazarus, Kanner, & Folkman, 1980; Ryff, 1989), in 2000, Seligman and Csikszentmihalyi raised the profile of the subfield by naming and drawing attention to what they called “positive psychology.” In their influential American Psychologist article, the authors noted:

Psychologists know very little about how normal people flourish under more benign conditions. Psychology has, since World War II, become a science largely about healing. It concentrates on repairing damage within a disease model of human functioning. This almost exclusive attention to pathology neglects the fulfilled individual and the thriving community. The aim of positive psychology is to begin to catalyze a change in the focus of psychology from preoccupation only with repairing the worst things in life to also building positive qualities. (Seligman & Csikszentmihalyi, 2000, p. 5)

In the past decade, there has been an exponential increase in studies of positive psychology that include specific focus on constructs like positive affect, life satisfaction, meaning and purpose, self-efficacy, and optimism, among others. Seligman and Csikszentmihalyi (2000) were emphasizing a need to look at flourishing under normal conditions. In the present chapter, we focus on the ways in which positive psychological constructs may play an adaptive role for people who are experiencing chronic disease or other forms of chronic life stress—an area of particular interest to health psychologists.

Two theories are particularly relevant to the role of positive psychological constructs in the context of chronic illness: Revised Stress and Coping Theory (Folkman, 1997) and the Broaden-and-Build theory of positive emotion (Fredrickson, 1998). Both theories are specific to positive affect but likely also apply to other related positive psychological constructs.

Folkman (1997) proposed a revision to Stress and Coping Theory that explicitly posits a role for positive affect in the coping process. According to the original theory (Lazarus & Folkman, 1984), the coping process begins when an event is appraised as threatening, harmful, or challenging. These appraisals are associated with affect (negative affect in response to threat or harm, a mix of positive and negative in response to challenge) and prompt coping. If the event is resolved favorably, a positive affective state is the result. If the event is resolved unfavorably or if it is unresolved, a negative affective state results and the coping process continues through reappraisal and another round of coping. The revised model suggests that the negative affect associated with unfavorable resolution motivates coping processes that draw on important goals and values, including positive reappraisal and goal-directed, problem-focused coping. These coping processes result in positive affect, which is hypothesized to serve important coping functions: For example, positive affect may provide a psychological “time-out” from the distress associated with chronic stress and help motivate and sustain ongoing efforts to cope with the situation (Lazarus et al., 1980). In the context of serious life stress such as living with a chronic illness, positive affect may facilitate adaptive coping and foster challenge appraisals that lead to more proactive and adaptive coping efforts.

Fredrickson (1998) proposed the “Broaden-and-Build” model of the function of positive emotion that complements Revised Stress and Coping Theory. In this model, the “broadening” function of positive affect enables the individual to see beyond the immediate stressor and possibly come up with creative alternative solutions to problems. The “building” function helps to rebuild resources (such as self-esteem and social support) depleted by enduring stressful conditions. In contrast to the narrowing of attention and specific action tendencies associated with negative affect, positive affect broadens the individual's attentional focus and behavioral repertoire. Repeated experiences of positive affect are inherently reinforcing, and build social, intellectual and physical resources. Although the Broaden-and-Build model was not developed specifically to address positive affect in the context of stress, under stressful conditions the functions of positive affect suggested by the model become especially important. In the context of stress, positive affect may prevent the individual from feeling overwhelmed, lead to more flexibility in coping efforts, and, ultimately, help build resilience to the stress.

Positive Psychology and Health Outcomes

Several of the constructs within the positive psychology framework have shown significant positive relationships with health outcomes, independent of the effects of negative affective constructs such as depression and anxiety. Positive affect, mastery and control, and meaning and purpose are among those with particular relevance to health and well-being. We will briefly describe some of the notable findings in each of these subdomains and highlight potential mechanisms of action, where applicable.

Positive Psychology Interventions

In this section, we briefly review the positive psychology interventions that have some evidence for efficacy in people coping with significant chronic conditions or illnesses. In addition, we focus on interventions that may be more appropriate for application within clinical health psychology settings. (For a broader review of positive interventions in a range of samples, see Moskowitz, 2010; Saslow, Cohn, & Moskowitz, in press.) Although there are therapies that target other positive psychological constructs, such as meaning or optimism (e.g., Bach & Hayes, 2002; Lee, Robin Cohen, Edgar, Laizner, & Gagnon, 2006; Singer, Singer, & Berry, 2013), the bulk of the experimental or clinical trials thus far have positive affect as the primary target of the intervention.

Assessment of Positive Constructs in Health Settings

Two complementary yet distinct approaches to conceptualization and measurement of positive constructs exist. Many researchers and theorists distinguish between: (1) “experienced” or hedonic well-being, typically captured by measures of positive affect, serenity, and happiness, and their converse, negative affect, despair, or distress, and (2) “evaluative” or global well-being, typically assessed through judgments of overall life satisfaction or of fulfillment on distinct domains of personal functioning, such as autonomy, personal growth, or meaning and purpose in life.

Recently, the National Institutes of Health (NIH) has made a concerted effort to improve measurement of neurological and behavioral function and this effort includes a focus on psychological well-being. The NIH Toolbox was one of the initiatives of the NIH Blueprint for Neuroscience Research (Gershon et al., 2010) and was designed to identify, create, and validate brief comprehensive assessment tools to measure outcomes in longitudinal, epidemiological, and intervention studies across the life span from ages 3 to 85 years. By providing a standard set of measures for cognition, emotion, motor, and sensory function across diverse study designs and populations, the goal was to maximize yield from large, expensive studies with minimal increment in subject burden and cost.

The NIH Toolbox made use of two approaches to significantly strengthen the measurement of positive psychological constructs: Item-response theory (IRT) and computerized adaptive testing (CAT). IRT is an alternate approach to classical test theory but unlike classical test theory, which describes scores relative to group-specific norms, IRT models the probability of a particular item response to the respondent's position on the underlying construct in question (Anastasi & Urbina, 1997; Lord, 1980; Richardson, 1936; Streiner & Norman, 1995). An IRT approach can be useful for providing item-level properties of an instrument across the full range of the construct.

CAT assessments are emerging options in the context of medical settings and/or clinical trials and offer a number of advantages. CAT exams are, on average, half as long as paper-and-pencil measures with equal or better precision (Embretson, 2006; Embretson & Reise, 2000; Weiss, 2004). Thus, such an application may allow for briefer, more efficient, more flexible, and more precise assessments, providing an opportunity to assess more domains of interest without adversely affecting respondent burden. This approach can yield a more robust and informative assessment battery.

Within the emotion domain of the NIH Toolbox, the mandate was to develop assessments with a broad focus, incorporating healthy emotional functioning. For the assessment of psychological well-being in adults ages 18 and older, item banks and short forms were created for three content areas: positive affect, life satisfaction, and meaning and purpose (Salsman et al., 2013). Although most measures of positive affect assess activated emotion (Cohen & Pressman, 2006), the Toolbox positive affect bank assesses both high-arousal (e.g., excitement, joy) and low-arousal (e.g., contentment, peace) positive affect. The activating nature of an emotion and not just its valence may be an important distinction for improving our understanding about the relation between psychological well-being and physical health.

The NIH Toolbox Life Satisfaction item bank assesses global or general satisfaction with life as captured by multiple items from the Satisfaction with Life Scale (Diener, Emmons, Larsen, & Griffin, 1985) and the Students' Life Satisfaction Scale (Huebner, 1991). The NIH Toolbox Meaning and Purpose item bank was created using items from a number of different sources, including the Meaning-in-Life Questionnaire (MLQ; Steger, Frazier, Oishi, & Kaler, 2006), the Life Engagement Test (Scheier et al., 2006), the Functional Assessment of Chronic Illness Therapy–Spiritual Well-Being Scale (Peterman, Fitchett, Brady, Hernandez, & Cella, 2002). All item banks can be administered as static short forms or as CAT assessments, providing the opportunity for optimal flexible, efficient, and precise assessment of these important dimensions of psychological well-being.

The field of health psychology is increasingly taking advantage of more fine-grained assessment approaches, such as the Day Reconstruction Method (Kahneman, Krueger, Schkade, Schwarz, & Stone, 2004) and applications of Ecological Momentary Assessment (EMA; Shiffman, Stone, & Hufford, 2008). Both methods could be adapted to be compatible with CAT approaches. EMA assesses phenomena at the moment they occur and in the subjects' natural environment, is dependent upon careful timing of assessments, and involves a substantial number of repeated observations (Shiffman et al., 2008). EMA uses real-time data capture, which enhances compliance, minimizes recall bias, and can capture diurnal rhythms, but it can miss important events and be burdensome and expensive (Stone, Shiffman, Atienza, & Nebling, 2007). An alternative approach to EMA is the Day Reconstruction Method (Kahneman et al., 2004), which involves a reconstruction of the recall period to assess affect, activities, and time use in everyday life. This process involves responding to standard life-satisfaction questions; segmenting the preceding day into episodes, like scenes in a movie; and asking detailed questions about the setting of each episode and participants' feelings. The Day Reconstruction Method allows for relatively rapid assessment of emotions and can be associated with time usage, but requires skilled interviewers and is costly. Notably, a comparison of ratings of experienced well-being obtained with EMA and the Day Reconstruction Method have found that the Day Reconstruction Method provides reasonably reliable estimates of the intensity of affect as well as variations in affect over the day, thus supporting its use as a viable methodology for assessing experienced well-being (Dockray et al., 2010).

Even though positive psychological constructs have been the focus of research for many years, there has been scant attention paid to optimal assessment of these constructs. The NIH Toolbox initiative and newer approaches, such as the Day Reconstruction Method, promise to enhance our understanding of positive psychology and its role in health and well-being.

Future Directions

As we have reviewed here, the science of health psychology and positive psychology holds significant promise for improving the lives of those affected by chronic illnesses and emerging research highlights the benefit of these subfields for enhancing adaptive health outcomes. Clearly, however, there is still some distance to cover before we declare positive health psychology a success. In particular, we suggest three areas for attention: (1) consideration of a wider array of positive constructs, both as targets for intervention and as independent variables in observational research; (2) attention to optimal measurement of these and other health-related constructs; and (3) designs that will allow the determination of which positive interventions work and for whom.

Health psychologists should expand the focus of observational and interventional studies to include a broader array of positive psychological constructs. In the present chapter, we discuss positive affect, optimism, meaning/purpose, and mastery/control in some depth and mention stress-related growth and mindfulness, but there are a number of other positive constructs that may prove to be important in terms of their role in health. Curiosity (Swan & Carmelli, 1996), humor (Martin, 2001, 2002; Martin & Lefcourt, 1983), grit (Duckworth, Peterson, Matthews, & Kelly, 2007), and self-compassion (Neff, 2003; Neff, Rude, & Kirkpatrick, 2007) are just a few examples of constructs that are garnering significant interest within the field. Rather than having each researcher pick a single construct on which to build a program, to the extent possible, studies should include multiple positive constructs in order to determine shared variance within the same study population. In this way, we will be able to move forward on the question of whether a given positive construct is uniquely important or if it is simply reflecting a common underlying construct of positivity.

In terms of measurement, the array of new options for measuring positive psychology constructs is very promising. Health psychologists should carefully consider the measures they select with an eye toward measures that are valid and reliable, certainly, but also as brief as possible and easy to fill out for patients coping with significant illness or life stress. Initiatives such as the NIH Toolbox are likely to clarify the options and allow researchers and clinicians to select the best outcome measures for their patient population. In addition to different approaches to measurement, such as CAT, we should also consider different ways to analyze the data we do collect. For example, Mroczek and colleagues (in press) recently demonstrated that level of positive and negative affect over the course of an 8-day diary study were not associated with 10-year mortality. However, the extent to which positive affect was reactive to daily stressful events did predict mortality, such that the more positive affect dropped in response to stress, the higher the likelihood of mortality over the course of the study period. Negative affect reactivity was not predictive. If the researchers had simply looked at level of positive and negative and not considered going a step further to consider the data in another way, the unique importance of emotional reactivity and mortality would likely have been lost.

As with the discussion of expanding our focus to include a broader array of positive constructs, an important next step is to begin to differentiate among the various positive constructs to determine whether there are significant differential effects or, instead, a core latent component that drives the benefits regardless of which positive construct is considered. Applications of IRT and CAT are particularly helpful in this regard, because they allow for a greater ability to assess more domains of interest with minimal respondent burden. Multiple positive domains could then be analyzed using a bifactor analysis in which the scales together load on a common factor but have separate factor loadings of their own. This could be a particularly illuminating approach to understanding the degree to which multiple positive constructs contribute to a global “positivity” factor and to help delineate to what extent the global versus the individual positive psychology component parts contribute to better health outcomes.

Information on which constructs are most effective and under what circumstances will help to tailor future interventions to specifically target the constructs that will most likely have the strongest beneficial effects. This is critically important because to optimize the strengths of positive health psychology, we need to determine what works and for whom. One potential determinant of intervention effectiveness may be the extent to which a disease has controllable aspects. Pressman and Cohen (2005) noted that positive affect seemed to have a bigger effect in illnesses that had some element of control, where behavioral strategies can have an impact, for example. If we extend these findings to positive interventions, we might hypothesize that for diseases where the individual's behavior can significantly influence outcomes (e.g., type-2 diabetes, cardiovascular disease) an intervention that specifically targets positive affect may be most effective, whereas for diseases or conditions in which there is less control (e.g., metastatic cancer) an intervention that targets meaning and purpose might be more applicable. Multicomponent interventions offer unique opportunities to examine the effects of a variety of skills and techniques for individuals with chronic health conditions but it is not always easy to identify what approaches work best and for which group of people from these intervention designs. A compelling and emerging strategy is the use of adaptive randomized controlled trials. Adaptive randomized controlled trials are flexible and efficient approaches to data collection because they increase the probability that a participant will be assigned to the best treatment (Chow & Chang, 2008; Coffey et al., 2012). These, and similar approaches, may prove particularly helpful in accelerating our understanding of the “active ingredients” of interventions and the mechanisms through which positive psychology impacts health. Ultimately, this will lead to better-designed interventions and individualized treatment plans, resulting in more patient-centered care and optimal health outcomes throughout the illness and health continuum.

Conclusion

Health psychologists who incorporate positive psychology into their practices are well-poised to address the needs of the growing population of patients, caregivers, and family members coping with the stress of chronic illness. Positive psychology holds promise for improving the lives of people living with chronic illness, and health psychologists are at the forefront of the observational and interventional research that will advance the field. However, as the field of positive health psychology matures, there is a danger of the pendulum swinging too far in the direction of overemphasis on positive constructs, while neglecting the importance and adaptational significance of negative affective constructs. A myopic focus on the positive runs the risk of ignoring the potential downsides that may be associated with positive affect (e.g., Gruber & Moskowitz, 2014). Furthermore, exclusive focus on the positive runs the risk of blaming the patient for not thinking the right positive thoughts that will improve his or her health or save his or her life. This focus is unfair and minimizes the very real stress and distress that often accompany chronic illness. Instead, we envision a positive health psychology that understands and values these very real and understandable negative emotions while making space alongside for the positive constructs.

Summary Points

• Health psychology is the scientific study of the relations of psychological factors, behavior, and the social environment with physical health and illness.
• The aim of positive psychology is to catalyze a change in the focus of psychology from preoccupation only with repairing the worst things in life to also building positive qualities.
• The Revised Stress and Coping and Broaden-and-Build theories are particularly relevant to the role of positive psychological constructs in the context of chronic illness.
• Positive psychology constructs (e.g., positive affect, self-efficacy, optimism, meaning and purpose in life) are uniquely related to beneficial health outcomes.
• Positive interventions (e.g., positive reappraisal, gratitude, acts of kindness) are demonstrating efficacy in people coping with chronic illness.
• New measurement approaches, such as the NIH Toolbox Psychological Well-Being item banks, have the potential to better capture the effects of these interventions.
• Measurement modalities such as the Day Reconstruction Method or applications of Ecological Momentary Assessment may provide innovative opportunities to assess and better understand the variable nature of some positive psychology constructs.
• Future work should consider a wider array of positive constructs both as targets for intervention and as independent variables in observational research. Future research should also attend to optimal measurement approaches of these and other health-related constructs and utilize research designs that allow the determination of which positive interventions work and for whom.

References

1. Anastasi, A., & Urbina, S. (1997). Psychological testing. Upper Saddle River, NJ: Prentice Hall.
2. Bach, P., & Hayes, S. C. (2002). The use of acceptance and commitment therapy to prevent the rehospitalization of psychotic patients: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 70(5), 1129.
3. Bandura, A. (1991). Self-efficacy mechanism in physiological activation and health-promoting behavior. In J. Madden (Ed.), Neurobiology of learning, emotion and affect. New York, NY: Raven Press.
4. Bandura, A. (1997). Self-efficacy: The exercise of control. New York, NY: W. H. Freeman.
5. Barskova, T., & Oesterreich, R. (2009). Post-traumatic growth in people living with a serious medical condition and its relations to physical and mental health: A systematic review. Disability and Rehabilitation, 31(21), 1709–1733.
6. Beckham, J. C., Burker, E. J., Lytle, B. L., Feldman, M. E., & Costakis, M. J. (1997). Self-efficacy and adjustment in cancer patients: A preliminary report. Journal of Behavioral Medicine, 23(3), 138–142.
7. Bränström, R., Duncan, L. G., & Moskowitz, J. T. (2011). The association between dispositional mindfulness, psychological well-being, and perceived health in a Swedish population-based sample. British Journal of Health Psychology, 16(2), 300–316. doi:10.1348/135910710x501683
8. Buck, A. C., Williams, D. R., Musick, M. A., & Sternthal, M. J. (2009). An examination of the relationship between multiple dimensions of religiosity, blood pressure, and hypertension. Social Science and Medicine, 68(2), 314–322. doi:10.1016/j.socscimed.2008.10.010
9. Caponigro, J. M., Moran, E. K., Kring, A. M., & Moskowitz, J. T. (2014). Awareness and coping with emotion in schizophrenia: Acceptability, feasibility and case illustrations. Clinical Psychology & Psychotherapy, 21(4), 371–380.
10. Carrico, A. W., & Moskowitz, J. T. (in press). Positive affect promotes engagement in care following HIV diagnosis. Health Psychology.
11. Chida, Y., & Steptoe, A. (2008). Positive psychological well-being and mortality: A quantitative review of prospective observational studies. Psychosomatic Medicine, 70(7), 741–756. doi: 10.1097/PSY.0b013e31818105ba
12. Chow, S.-C., & Chang, M. (2008). Adaptive design methods in clinical trials—A review. Orphanet Journal of Rare Diseases, 3(11).
13. Coffey, C. S., Levin, B., Clark, C., Timmerman, C., Wittes, J., Gilbert, P., & Harris, S. (2012). Overview, hurdles, and future work in adaptive designs: Perspectives from a National Institutes of Health-funded workshop. Clinical Trials, 9(6), 671–680.
14. Cohen, S., & Pressman, S. D. (2006). Positive affect and health. Current Directions in Psychological Science 15(3), 122–125. doi:10.1111/j.0963-7214.2006.00420.x
15. Compton, W. C. (2001). Toward a tripartite factor structure of mental health: Subjective well-being, personal growth, and religiosity. Journal of Psychology, 135(5), 486–500.
16. Diener, E., Emmons, R. A., Larsen, R. J., & Griffin, S. (1985). The Satisfaction with Life Scale. Journal of Personality Assessment, 49(1), 71–75. doi:10.1207/s15327752jpa4901_13
17. Dockray, S., Grant, N., Stone, A. A., Kahneman, D., Wardle, J., & Steptoe, A. (2010). A comparison of affect ratings obtained with Ecological Momentary Assessment and the Day Reconstruction Method. Social Indicators Research, 99(2), 269–283.
18. Dowling, G. A., Merrilees, J., Mastick, J., Chang, V. Y., Hubbard, E., & Moskowitz, J. T. (in press). Life enhancing activities for family caregivers of people with frontotemporal dementia. Alzheimer's Disease and Associated Disorders.
19. Duckworth, A. L., Peterson, C., Matthews, M. D., & Kelly, D. R. (2007). Grit: Perseverance and passion for long-term goals. Journal of Personality and Social Psychology, 92(6), 1087.
20. Duckworth, A. L., Steen, T. A., & Seligman, M. E. (2005). Positive psychology in clinical practice. Annual Review of Clinical Psychology, 1, 629–651.
21. Dunn, E. W., Aknin, L. B., & Norton, M. I. (2008). Spending money on others promotes happiness. Science, 319(5870), 1687–1688.
22. Edmondson, K., Lawler, K., Jobe, R., Younger, J., Piferi, R., & Jones, W. (2005). Spirituality predicts health and cardiovascular responses to stress in young adult women. Journal of Religion and Health, 44(2), 161–171. doi:10.1007/s10943-005-2774-0
23. Embretson, S. E. (2006). The continued search for nonarbitrary metrics in psychology. American Psychologist American Psychologist, 61(1), 50–55.
24. Embretson, S. E., & Reise, S. P. (2000). Item response theory for psychologists. Mahwah, NJ: Erlbaum.
25. Emmons, R. A. (2007). Thanks!: How the new science of gratitude can make you happier. New York, NY: Houghton Mifflin.
26. Emmons, R. A., & McCullough, M. E. (2003). Counting blessings versus burdens: An experimental investigation of gratitude and subjective well-being in daily life. Journal of Personality and Social Psychology, 84, 377–389.
27. Folkman, S. (1997). Positive psychological states and coping with severe stress. Social Science and Medicine, 45, 1207–1221.
28. Ford, B. Q., & Mauss, I. B. (in press). The paradoxical effects of pursuing positive emotion: When and why wanting to feel happy backfires. In J. M. Gruber, J. T. Moskowitz (Ed.), The dark and light sides of positive emotion. New York, NY: Oxford University Press.
29. Fredrickson, B. L. (1998). What good are positive emotions? Review of General Psychology, 2, 300–319.
30. Gershon, R. C., Cella, D., Fox, N. A., Havlik, R. J., Hendrie, H. C., & Wagster, M. V. (2010). Assessment of neurological and behavioural function: The NIH Toolbox. Lancet Neurology, 9(2), 138–139. doi:S1474-4422(09)70335-7 [pii] 10.1016/S1474-4422(09)70335-7
31. Gruber, J., & Moskowitz, J. T. (Eds.). (2014). The dark and light sides of positive emotion. New York, NY: Oxford University Press.
32. Hoogwegt, M. T., Versteeg, H., Hansen, T. B., Thygesen, L. C., Pedersen, S. S., & Zwisler, A.-D. (2013). Exercise mediates the association between positive affect and 5-year mortality in patients with ischemic heart disease. Circulation: Cardiovascular Quality and Outcomes. doi:10.1161/circoutcomes.113.000158
33. Huebner, E. S. (1991). Initial development of the Student's Life Satisfaction Scale. School Psychology International, 12(3), 231–240. doi:10.1177/0143034391123010
34. Huffman, J. C., Mastromauro, C. A., Boehm, J. K., Seabrook, R., Fricchione, G. L., Denninger, J. W., & Lyubomirsky, S. (2011). Development of a positive psychology intervention for patients with acute cardiovascular disease. Heart International, 6(2), e14.
35. Isen, A. M., & Shalker, T. E. (1982). The effect of feeling state on evaluation of positive, neutral, and negative stimulie: When you “accentuate the positive,” do you “eliminate the negative”? Social Psychology Quarterly, 45, 58–63.
36. Ishida, R., & Okada, M. (2006). Effects of a firm purpose in life on anxiety and sympathetic nervous activity caused by emotional stress: Assessment by psycho-physiological method. Stress and Health, 22(4), 275–281. doi:10.1002/smi.1095
37. Jahoda, M. (1958). Current concepts of positive mental health. New York, NY: Basic Books.
38. Jones, F., Partridge, C., & Reid, F. (2008). The Stroke Self-Efficacy Questionnaire: Measuring individual confidence in functional performance after stroke. Journal of Clinical Nursing, 17(7b), 244–252.
39. Kahneman, D., Krueger, A. B., Schkade, D. A., Schwarz, N., & Stone, A. A. (2004). A survey method for characterizing daily life experience: The Day Reconstruction Method. Science, 306(5702), 1776–1780. doi:10.1126/science.1103572
40. Klinger, E. (2012). The search for meaning in evolutionary perspective and its clinical implications. In P. T. P. Wong & P. S. Fry (Eds.), The human quest for meaning: A handbook of psychological research and clinical applications (2nd ed., pp. 23–56). Mahwah, NJ: Erlbaum.
41. Krause, N. (2009). Meaning in life and mortality. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 64B(4), 517–527. doi:10.1093/geronb/gbp047
42. Krause, N., & Shaw, B. A. (2003). Role-specific control, personal meaning, and health in late life. Research on Aging, 25(6), 559–586. doi:10.1177/0164027503256695
43. Lancastle, D., & Boivin, J. (2007, December). Feasibility, acceptability and usefulness of a self-administered positive reappraisal coping intervention (PRCI) card for stressful medical situations. Paper presented at the 3rd Annual Meeting of the United Kingdom Society for Behavioural Medicine, Warwick, England.
44. Lancastle, D., & Boivin, J. (2008). A feasibility study of a brief coping intervention (PRCI) for the waiting period before a pregnancy test during fertility treatment. Human Reproduction, 23, 2299–2307.
45. Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York, NY: Springer.
46. Lazarus, R. S., Kanner, A. D., & Folkman, S. (1980). Emotions: A cognitive-phenomenological analysis. In R. Plutchik & H. Kellerman (Eds.), Theories of emotion (pp. 189–217). New York, NY: Academic Press.
47. Lee, V., Robin Cohen, S., Edgar, L., Laizner, A. M., & Gagnon, A. J. (2006). Meaning-making intervention during breast or colorectal cancer treatment improves self-esteem, optimism, and self-efficacy. Social Science and Medicine, 62(12), 3133–3145.
48. Linde, J. A., Rothman, A. J., Baldwin, A. S., & Jeffery, R. W. (2006). The impact of self-efficacy on behavior change and weight change among overweight participants in a weight loss trial. Health Psychology, 25(3), 282–291. doi:10.1037/0278-6133.25.3.282
49. Lord, F. M. (1980). Applications of item response theory to practical testing problems. Hillsdale, NJ: Erlbaum.
50. Mancuso, C. A., Choi, T. N., Westermann, H., Wenderoth, S., Hollenberg, J. P., Wells, M. T.,…Charlson, M. E. (2012). Increasing physical activity in patients with asthma through positive affect and self-affirmation: A randomized trial. Archives of Internal Medicine, 172, 337–343. doi:10.1001/archinternmed.2011.1316
51. Martin, R. A. (2001). Humor, laughter, and physical health: Methodological issues and research findings. Psychological Bulletin, 127(4), 504–519.
52. Martin, R. A. (2002). Is laughter the best medicine? Humor, laughter, and physical health. Current Directions in Psychological Science, 11(6), 216–220.
53. Martin, R. A., & Lefcourt, H. M. (1983). Sense of humor as a moderator of the relation between stressors and moods. Journal of Personality & Social Psychology, 45(6), 1313–1324.
54. Matthews, K. A., Owens, J. F., Edmundowicz, D., Lee, L., & Kuller, L. H. (2006). Positive and negative attributes and risk for coronary and aortic calcification in healthy women. Psychosomatic Medicine, 68(3), 355–361. doi:10.1097/01.psy.0000221274.21709.d0
55. Meredith, P., Strong, J., & Feeney, J. A. (2006). Adult attachment, anxiety, and pain self-efficacy as predictors of pain intensity and disability. Pain, 123(1–2), 146–154. doi:10.1016/j.pain.2006.02.025
56. Moen, P., Dempster-McCain, D., & Williams, R. M. (1993). Successful aging. American Journal of Sociology, 97, 1612–1632.
57. Moskowitz, J. T. (2010). Coping interventions and the regulation of positive affect. In S. Folkman (Ed.), The Oxford handbook of stress, health, and coping (pp. 407–427). Oxford, England: Oxford University Press.
58. Moskowitz, J. T., Hult, J. R., Duncan, L. G., Cohn, M. A., Maurer, S. A., Bussolari, C., & Acree, M. (2012). A positive affect intervention for people experiencing health-related stress: Development and non-randomized pilot test. Journal of Health Psychology, 17(5), 677–693. doi:10.1177/1359105311425275
59. Mroczek, D. K., Stawski, R. S., Turiano, N. A., Chan, W., Almeida, D. M., Neupert, S. D., & Spiro, A. (in press). Emotional reactivity and mortality: Longitudinal findings from the VA Normative Aging Study. Journals of Gerontology: Psychological Sciences.
60. Musick, M. A., & Wilson, J. (2003). Volunteering and depression: The role of psychological and social resources in different age groups. Social Science & Medicine, 56, 259–269.
61. Neff, K. (2003). Self-compassion: An alternative conceptualization of a healthy attitude toward oneself. Self and Identity, 2(2), 85–101.
62. Neff, K. D., Rude, S. S., & Kirkpatrick, K. L. (2007). An examination of self-compassion in relation to positive psychological functioning and personality traits. Journal of Research in Personality, 41(4), 908–916.
63. Ogden, J. (2012). Health psychology: A textbook (5th ed.). Maidenhead, England: Open University Press.
64. Ogedegbe, G. O., Boutin-Foster, C., Wells, M. T., Allegrante, J. P., Isen, A. M., Jobe, J. B., & Charlson, M. E. (2012). A randomized controlled trial of positive-affect intervention and medication adherence in hypertensive African Americans. Archives of Internal Medicine, 172(4), 322.
65. Oman, D., Thoresen, C. E., & McMahon, K. (1999). Volunteerism and mortality among the community-dwelling elderly. Journal of Health Psychology, 4, 301–316.
66. Ozaki, A., Uchiyama, M., Tagaya, H., Ohida, T., & Ogihara, R. (2007). The Japanese Centenarian Study: Autonomy was associated with health practices as well as physical status. Journal of the American Geriatrics Society, 55(1), 95–101.
67. Peterman, A. H., Fitchett, G., Brady, M. J., Hernandez, L., & Cella, D. (2002). Measuring spiritual well-being in people with cancer: The Functional Assessment of Chronic Illness Therapy-Spiritual Well-being Scale (FACIT-Sp). Annals of Behavioral Medicine, 24(1), 49–58.
68. Peterson, J. C., Charlson, M. E., Hoffman, Z., Wells, M. T., Wong, S.-C., Hollenberg, J. P.,…Allegrante, J. P. (2012). Randomized controlled trial of positive affect induction to promote physical activity after percutaneous coronary intervention. Archives of Internal Medicine, 172, 329–336. doi:10.1001/archinternmed.2011.1311
69. Peterson, J. C., Czajkowski, S., Charlson, M. E., Link, A. R., Wells, M. T., Isen, A. M.,…Ogedegbe, G. (2013). Translating basic behavioral and social science research to clinical application: The EVOLVE mixed methods approach. Journal of Consulting and Clinical Psychology, 81(2), 217.
70. Post, S. G. (2005). Altruism, happiness, and health: It's good to be good. International Journal of Behavioral Medicine, 12, 66–77.
71. Pressman, S. D., & Cohen, S. (2005). Does positive affect influence health? Psychological Bulletin, 131(6), 925–971. doi:10.1037/0033-2909.131.6.925
72. Rahman, A., Reed, E., Underwood, M., Shipley, M. E., & Omar, R. Z. (2008). Factors affecting self-efficacy and pain intensity in patients with chronic musculoskeletal pain seen in a specialist rheumatology pain clinic. Rheumatology, 47(12), 1803–1808. doi:10.1093/rheumatology/ken377
73. Richardson, M. (1936). The relation between the difficulty and the differential validity of a test. Psychometrika, 1(2), 33–49. doi:10.1007/BF02288003
74. Ryff, C. D. (1989). Happiness is everything, or is it? Exploration on the meaning of psychological well-being. Journal of Personality and Social Psychology, 57(6), 1069–1081.
75. Salsman, J., Lai, J.-S., Hendrie, H., Butt, Z., Zill, N., Pilkonis, P.,…Cella, D. (2013). Assessing psychological well-being: Self-report instruments for the NIH Toolbox. Quality of Life Research, 23(1), 205–215. doi:10.1007/s11136-013-0452-3
76. Saslow, L. R., Cohn, M., & Moskowitz, J. T. (in press). Positive affect interventions to reduce stress: Harnessing the benefit while avoiding the Pollyanna. In J. Gruber & J. T. Moskowitz (Eds.), The dark and light sides of positive emotion. New York, NY: Oxford University Press.
77. Scheier, M., Wrosch, C., Baum, A., Cohen, S., Martire, L., Matthews, K.,…Zdaniuk, B. (2006). The Life Engagement Test: Assessing purpose in life. Journal of Behavioral Medicine, 29(3), 291–298.
78. Schwerdtfeger, A., Konermann, L., & Schönhofen, K. (2008). Self-efficacy as a health-protective resource in teachers? A biopsychological approach. Health Psychology, 27(3), 358–368.
79. Seligman, M. E. P., & Csikszentmihalyi, M. (2000). Positive psychology: An introduction. American Psychologist, 55(1), 5. doi:10.1037/0003-066X.55.1.5
80. Selye, H. (1956). The stress of life. New York, NY: McGraw-Hill.
81. Shiffman, S., Stone, A. A., & Hufford, M. R. (2008). Ecological Momentary Assessment. Annual Review of Clinical Psychology, 4(1), 1–32. doi:10.1146/annurev.clinpsy.3.022806.091415
82. Singer, J. A., Singer, B. F., & Berry, M. (2013). A meaning-based intervention for addiction: Using narrative therapy and mindfulness. In J. A. Hicks & C. Routledge (Eds.), The experience of meaning in life: Classical perspectives, emerging themes, and controversies (pp. 379–392). Dordrecht, The Netherlands: Springer.
83. Steger, M. F., Frazier, P., Oishi, S., & Kaler, M. (2006). The Meaning in Life Questionnaire: Assessing the presence of and search for meaning in life. Journal of Counseling Psychology, 53(1), 80–93. doi:10.1037/0022-0167.53.1.80
84. Stone, A. A., Shiffman, S., Atienza, A., & Nebling, L. (2007). The science of real-time data capture: Self-reports in health research. New York, NY: Oxford University Press.
85. Streiner, D. L., & Norman, G. R. (1995). Health measurement scales: A practical guide to their development and use. Oxford, England: Oxford University Press.
86. Swan, G. E., & Carmelli, D. (1996). Curiosity and mortality in aging adults: A 5-year follow-up of the Western Collaborative Group Study. Psychology and Aging, 11(3), 449.
87. Weiss, D. J. (2004). Computerized adaptive testing for effective and efficient measurement in counseling and education. Measurement and Evaluation in Counseling and Development, 37(2), 70–84.
88. Wu, S., & Green, A. (2000). Projection of chronic illness prevalence and cost inflation. Washington, DC: RAND Health.
89. Zautra, A. J., Davis, M. C., Reich, J. W., Nicassario, P., Tennen, H., Finan, P.,…Irwin, M. R. (2008). Comparison of cognitive behavioral and mindfulness meditation interventions on adaptation to rheumatoid arthritis for patients with and without history of recurrent depression. Journal of Consulting and Clinical Psychology, 76(3), 408–421.
90. Zika, S., & Chamberlain, K. (1992). On the relation between meaning in life and psychological well-being. British Journal of Psychology, 83(Pt. 1), 133–145.