Cráneofacial

Applied positive psychology and well-being

Since its emergence in 1998, positive psychology has flourished in many aspects.

Perhaps one of the most successful developments within the field was the discipline of applied positive psychology, which has been defined as the “science and practice of improving well-being” (Lomas, Hefferon & Ivtzan, 2015, p. 1347). The core of applied positive psychology are positive psychological interventions (PPIs), some of which principles have been piloted in early 1980s (Fordyce, 1981; 1983). Since then, there has been a notable growth in different PPIs designed to promote well-being in many practical ways (Parks & Biswas-Diener, 2014), although the criteria “necessary and sufficient” for recognising interventions as PPIs are still being debated (Lomas et al., 2015, p. 1348). According to Nancy Sin and Sonja Lyubomirsky (2009), PPIs are:

Treatment methods or intentional activities that aim to cultivate positive feelings, behaviours or cognitions… Programs, interventions, or treatments aimed at fixing,

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remedying, or healing something that is pathological or deficient – as opposed to building strengths – do not fit the definition of a PPI (p. 468).

However, this does not mean that PPIs could not be used to address mental health, even in clinical medical populations (Macaskill, 2016). Although most traditional treatment approaches focus on alleviating symptoms of mental illness, rather than building positive qualities and resources (Sin, Della Porta & Lyubomirsky, 2011), a number of studies have shown successful applications of PPIs to mental health disorders, such as depression (Sin &

Lyubomirsky, 2009), addiction (Krentzman, 2013), alcohol misuse (Akhtar & Boniwell, 2010), eating disorders (Harrison, Al-Khairulla & Kikoler, 2016), and schizophrenia (Meyer et al., 2012).

It has been well established in mood research that positive affect and negative affect are two separate constructs (Watson & Tellegen, 1985), and thus the mere absence of negative emotions cannot be equivalent to the presence of positive ones. Indeed, there are individuals who may not suffer with any particular mental illness, yet still feel generally unhappy and incapable of effective functioning in everyday life (Keyes, 2007). Similarly, people with diagnosis of mental illness may feel generally happy and cope well with their mental health condition, altogether living a life of good quality (Bergsma, ten Have, Veenhoven & de Graaf, 2011). Well-being refers to individual’s appraisal of their life as a whole, including emotional responses, domain satisfactions, and global judgements of life satisfactions (Diener et al., 1999), leading to an “optimal psychological functioning and experience” (Ryan & Deci, 2001, p. 142).

Historically, the construct of well-being has been studied from two perspectives, the perspective of happiness or hedonic well-being, often referred to as subjective well-being; and the perspective of human potential or eudaimonic well-being, often referred to as psychological

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well-being (Keyes, Shmotkin & Ryff, 2002). However, increasing evidence suggests that although these two are “related but distinct aspects of positive psychological functioning”

(Keyes et al., 2002, p. 1009), understanding of well-being may be enhanced by measuring both aspects (Green, Oades & Grant, 2006). Extensive cross-sectional and longitudinal research has identified a wide range of benefits of well-being in different life domains, including health, recovery from physical illness and longevity (Diener & Chan, 2011; Howell, Kern &

Lyubomirsky, 2007; Lamers, Bolier, Westerhof, Smit & Bohlmeijer, 2012). Additionally, research has found links between subjective and psychological well-being and reduced mortality risks in individuals with physical disease (Chida & Steptoe, 2008; Lamers et al., 2012), and reduced risk of developing mental disorders or related symptoms (Keyes, Dhingra

& Simoes, 2010; Wood & Joseph, 2010). (See Bolier, Haverman, Westerhof et al., 2013b for a review).

A review of research in optimism revealed that optimism, positive affect and subjective well-being are associated with better health and reduced mortality even after controlling for depression and negative affect (Rasmussen et al., 2009). Furthermore, it has been discovered that positive emotions help individuals recover faster from negative emotional experiences (Fredrickson & Levenson, 1998, Tugade & Fredrickson, 2004), and prevent relapse episodes (Fava & Ruini, 2003) by improving related coping mechanisms (Garland, Fredrickson, Kring et al., 2010) and triggering upward spirals toward greater psychological well-being (Fredrickson & Joiner, 2002). A number of evaluation studies have demonstrated the efficacy of engaging in intentional, effortful activities, such as expressing gratitude (Lyubomirsky, Dickerhoof, Boehm, & Sheldon, 2011; Seligman et al., 2005; Sheldon & Lyubomirsky, 2006), counting blessings (Emmons & McCullough, 2003; Froh, Sefick, & Emmons, 2008;

Lyubomirsky, Sheldon & Schkade, 2005; Seligman et al., 2005), practicing optimism (Sheldon

& Lyubomirsky, 2006), performing acts of kindness (Boehm, Lyubomirsky, & Sheldon, 2011;

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Lyubomirsky et al., 2005b; Otake, Shimai, Tanaka-Matsumi, Otsui & Fredrickson, 2006), setting personal goals (Green et al., 2006; Sheldon, Kasser, Smith & Share, 2002), and using one’s signature character strengths (Seligman et al., 2005) to enhance well-being, and, in some cases, to alleviate symptoms of depression (Seligman et al., 2005).

Since the main focus of positive psychology is well-being, not an illness (Park, Peterson

& Seligman, 2004), it is not surprising that most research has been conducted in non-clinical populations. However, in recent years an increasing amount of evidence has been emerging to suggest that positive psychology is beginning to be applied in the health care context (Macaskill, 2016). A number of studies have examined positive psychology concepts in relation to the likelihood of a diagnosis of an illness. For example, high levels of hope and curiosity have been found to decrease the likelihood of a diagnosis of diabetes or hypertension (Richman, Kubzansky, Maselko et al., 2005). Several randomised controlled trials have shown that positive psychology related interventions lead to improved health-related behaviours in patients with heart and lung disease (Mancuso, Choi, Westermann et al., 2012; Ogedegbe, Boutin-Foster, Wells et al., 2012; Peterson, Charlson, Hoffman et al., 2012). A number of PPIs involving positive psychological concepts of optimism, and gratitude have even been developed specifically for patients with cardiovascular disease (DuBois, Millstein, Celano, Wexler & Huffman, 2016; Huffman, Mastromauro, Boehm et al., 2011), and type 2 diabetes (Huffman, DuBois, Millstein, Celano & Wexler, 2015). Most studies reviewed included optimism, featured in the Values-in-Action Classification (Peterson & Seligman, 2004), as the main character strength measured.

Interestingly, optimism seems to be related to better health outcomes, reduced symptoms and adaptation to a chronic illness in patients with a number of physical health conditions related to obesity, such as hypertension (Conway, Magai, Springer & Jones, 2008), diabetes (Brody, Kogan, Murry, Chen & Brown, 2008; De Ridder, Fournier & Bensing, 2004;

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Fournier, De Ridder & Bensing, 2002a; Fournier, De Ridder & Bensing, 2002b), cardiovascular disease (Shepperd, Maroto & Pbert, 1996; Shnek, Irvine, Stewart & Abbey, 2001), and osteoarthritis (Ferreira & Sherman, 2007). Similarly, decreased optimism seems to be indicative of poorer health conditions in these patients (Motivala, Hurwitz, LaGreca et al., 1999). Additionally, when compared to individuals of a more pessimistic nature, optimistic people report less pain (Affleck, Tennen, Zautra et al., 2001; Costello, Bragdon, Light et al., 2002, Mahler & Kulik, 2000; Smith & Zautra, 2004), better physical functioning (De Ridder et al., 2004; Fournier et al., 2002a, Fournier et al., 2002b; Motivala et al., 1999), fewer physical symptoms (Fournier et al., 2002a, Glazer, Emery, Frid & Banyasz, 2002; Kurdek & Siesky, 1990; Lyons & Chamberlain, 1994; Motivala et al., 1999; Northouse, Caffey, Deichelbohrer et al., 1999), and are less likely to be rehospitalized after undergoing a coronary artery bypass surgery (Scheier, Matthews, Owens et al., 1999). (See Rasmussen et al., 2009 for a review.)

Although evidence consistently suggests that positive psychological well-being protects against cardiovascular disease, the vast majority of studies have employed cross-sectional designs, making it difficult to determine whether positive psychological well-being influences biology or vice versa (Boehm & Kubzansky, 2012). An association has been found between certain aspects of eudaimonic well-being and the amount of lipids in adults (Boehm

& Kubzansky, 2012). In particular, adolescent self-sufficiency has been linked to lower levels of total cholesterol in adult men, after adjusting for lifestyle and biological factors (Twisk, Snel, Kemper & van Mechelen, 1998). Several studies have also reported inverse associations between eudaimonic well-being and adult BMI (e.g. Carr & Friedman, 2005). However, evidence from longitudinal research has been somewhat inconsistent in this respect, with some studies suggesting links between well-being and reduced risk of being overweight (Gale, Batty

& Deary, 2008), but others reporting no significant associations (Roberts, Troop, Connan, Treasure, & Campbell, 2007). (See Boehm & Kubzansky, 2012 for a review.) Additionally,

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certain aspects of hedonic well-being, (particularly positive affect), have been associated with lower levels of IL-6⁷ (Steptoe, O’Donnell, Badrick, Kumari & Marmot, 2008). Concretely trait positive affect was related to lower levels of stimulated IL-6 in adults (Prather, Marsland, Muldoon, & Manuck, 2007). It has been shown that IL-6 increases hepatic triglyceride secretion (Nonogaki, Fuller, Fuentes et al., 1995) and may therefore, contribute to the hypertriglyceridemia associated with visceral obesity (see Frühbeck, Gómez-Ambrosi, Muruzábal, & Burrell, 2001 for a review).

Applying positive psychology to treat disordered eating

Eating disorders (EDs), including anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED) and avoidant/restrictive food intake disorder (ARFID), present serious mental health difficulties, and are known to be one of the most challenging psychiatric disorders to treat (Halmi, Tozzi, Thornton et al., 2005). It becomes even more difficult to treat if the illness continues into adulthood (Halmi et al., 2005, Steinhausen, 2009), and 25% of patients struggle with disordered eating for the rest of their lives (Steinhausen, 2009) with at least 10% experiencing subclinical EDs (Lähteenmäki, Saarni, Suokas et al., 2014). Traditional research on EDs has focused primarily on identifying and addressing risk factors and symptoms of disordered eating. Indeed, substantial amount of evidence confirms that CBT effectively eliminates binge eating and purging in about 50% of patients with BN (Wilson & Fairburn, 2007), and there is strong empirical support for its effectiveness for BED (Apple & Agras, 1997; Fairburn, Marcus & Wilson, 1993).

Despite many successful applications of CBT to EDs, there are still high numbers of individuals with incomplete responses to treatment, and premature drop-outs from the therapy

7 Interleukin 6 (IL-6) is a protein secreted by adipose tissue encoded by the IL6 gene (Ferguson-Smith, Chen, Newman et al., 1988), and it is implicated in host defence and in glucose and lipid metabolism (Mohamed-Ali, Pinkney & Coppack, 1998).

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(Kristeller, Baer & Wolever, 2006). Most chronic patients with EDs experience failure of traditional therapeutic approaches throughout their long history of illness, and do not improve through short-term motivational interviewing (Nagata, 2009). Therefore, it seems necessary to find interventions that would tackle disordered eating more comprehensively.

In recent years, researchers have become more interested in the application of a positive psychology framework to promote factors that protect against disordered eating (Steck, Abrams & Phelps, 2004). For example, research in the effects of positive emotions has proven to be particularly relevant to the study of EDs psychopathology (Tchanturia, et al., 2015).

Evidence from theoretical and empirical studies consistently shows that individuals with EDs often struggle with emotional processing (Oldershaw, Hambrook, Stahl et al., 2011), which has negative impact on their quality of life (Tchanturia, Hambrook, Curtis et al., 2013), and contributes to high social anhedonia experienced by people with EDs (Harrison, Mountford &

Tchanturia, 2014; Tchanturia, Davies, Harrison et al., 2012) and a limited number of relationships (Doris, Westwood, Mandy & Tchanturia, 2014). Experimental evidence shows that patients with EDs have difficulties with flexible thinking and being able to see the bigger picture (Lang, Lopez, Stahl, Tchanturia & Treasure, 2014), which may be one of the reasons preventing them from moving towards recovery.

According to the Broaden-and-build theory (Fredrickson, 1998, 2001) positive emotions broaden people’s thought-action repertoires, by which they can help counteract the effect of negative emotions and build resilience (Cohn, Fredrickson, Brown, Mikels &

Conway, 2009; Fredrickson, 2001). Enhancing their experience of positive emotion on a regular basis, PPIs may help patients with EDs to develop better coping strategies regarding their health behaviours, and become more flexible and creative in finding alternative solutions to problems (Tchanturia et al., 2015). Indeed, higher levels of positive emotion, engagement and meaning in life have been linked with decreased ED symptomatology in female adolescents

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(Góngora, 2014), and a number of preliminary investigations have indicated emotion-focused therapy as an efficient treatment for AN (see Sala, Heard & Black, 2016 for a review). A recent study investigating the effects of group PPI on the well-being of patients with an unspecified ED revealed significant improvements in the patients’ subjective happiness and life satisfaction after the intervention, which was also maintained six months later (Harrison et al., 2016).

A growing body of literature is emerging on the application of mindfulness-based approaches to the treatment of EDs and obesity-related eating behaviours, some of which are adaptations of previously developed therapies, such as dialectical behaviour therapy (DBT;

Linehan, 1993), mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2002), acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999), and mindfulness-based eating awareness training (MB-EAT; Kristeller & Hallett, 1999), which has been developed specifically for BED.

Mindfulness-based interventions are programs aimed at developing skills that reduce distress and improve well-being through systematic training in various mindfulness techniques and exercises (Kristeller & Wolever, 2011). It has been suggested that cultivation of these skills may play an important role in individuals’ ability to alter their maladaptive relationship with food by increasing awareness of emotional and sensory cues, and thus, enhancing self-regulatory mechanisms (Dalen et al., 2010; Kristal, Littman, Benitez & White, 2005; Kristeller

& Wolever, 2011; Leahey, Crowther & Irwin, 2008; Shapiro, Carlson, Astin & Freedman, 2006). A number of recent reviews indicated that mindfulness-based therapies may be an effective form of treatment for EDs (Godsey, 2013; Berghe, Sanz-Valero & Wanden-Berghe, 2011), and obesity-related eating pathology (Godsey, 2013; Katterman et al., 2014;

O'Reilly et al., 2014), with some researchers even proposing that mindfulness is an essential component of holistic obesity treatment (Douglass, 2011; Kristeller & Wolever, 2011). Indeed, studies have demonstrated that mindfulness approaches improve or extend long term health

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outcomes in individuals with EDs (Hepworth, 2011), and are also associated with reduction of overall food consumption, healthier food choices, and practices that slow the eating process among obese individuals (Daubenmier, Kristeller, Hecht et al., 2011; Field, 2011; 2016).

Several studies have reported decreases in binge eating frequency and/or severity in response to a mindfulness intervention (Baer, Fischer & Huss, 2005; Courbasson, Nishikawa

& Shapira , 2011; Kristeller & Hallett, 1999; Kristeller, Wolever & Sheets 2014; Leahey et al., 2008; Smith, Shelley, Leahigh & Vanleit, 2006; Smith, Shelley, Dalen et al., 2008; Tapper, Shaw, Ilsley et al., 2009; Woolhouse, Knowles & Crafti, 2012) highlighting the importance of these findings for obesity treatment, as binge eating is the most commonly reported problematic eating behaviour among obese individuals (Tanofsky-Kraff, Wilfley, Young et al., 2007), which has been associated with an early onset of obesity (Mussell, Mitchell, De Zwaan et al., 1996), and its maintenance and greater severity (Bruce & Argas, 1992; Picot & Lilenfeld, 2003). In particular, improvements in binge eating behaviours were observed in studies that used a combination of mindfulness and cognitive behavioural therapies (Baer et al., 2005;

Leahey et al., 2008; Woolhouse et al., 2012; Courbasson et al., 2011), mindful eating programs (Dalen et al., 2010; Kristeller et al., 2014), acceptance based practices (Tapper et al., 2009), and different combinations of mindfulness exercises (Kristeller & Hallett, 1999; Alberts, Mulkens, Smeets, & Thewissen, 2010). (See O’Reilly et al., 2014 for a more detailed review.) Additionally, in studies where weight data were reported, engaging in mindfulness-based interventions has led to reductions in weight, and BMI (Alberts et al., 2010; Dalen et al., 2010;

Kristeller et al., 2014; Miller, Kristeller, Headings, Nagaraja & Miser, 2012; Netam, Yadav, Khadgawat, Sarvottam & Yadav 2015; Niemer et al., 2012) or stabilization of weight among obese individuals (Daubenmier et al., 2011), with some also reporting reduced levels of blood glucose and pro-inflammatory cytokines including IL-6 (Netam et al., 2015). In contrast, there have been studies which identified no positive changes in participants’ eating behaviour in

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response to a mindfulness-based intervention (Kearney, Milton, Malte et al., 2012; Kidd, Graor

& Murrock, 2013), with some even reporting increased body weight after the intervention (Kearney et al., 2012; Rosenzweig, Reibel, Greeson et al., 2007).

Out of all positive psychological concepts, in relation to EDs treatment, mindfulness has undoubtedly been studied the most extensively. However, the importance of other aspects of positive psychology, such as gratitude (Geraghty, Wood & Hyland, 2010; Wolfe &

Patterson, 2017), compassion (Kelly & Carter, 2015; Kelly, Vimalakanthan & Carter, 2014;

Pinto-Gouveia et al., 2017), hope (Boisvert & Harrell, 2013a; Irving & Cannon, 2000), spirituality (Boisvert & Harrell, 2012; Boisvert & Harrell, 2013b), meaning in life (Góngora, 2014), and forgiveness (Sesan, 2009) has also been addressed in the literature with several studies discussing the importance of positive psychology in the process of recovery from mental illness (e.g. Schrank, Brownell, Tylee & Slade, 2014; Slade, 2010). Practicing unconditional acceptance and relating to one's present life circumstances and feelings with compassion (Brach, 2003) has been proposed as central to recovery from EDs, as it opens the way to forgiveness by providing the patients with “tools that enable them to transcend the narrow focus on self and symptoms that prevent connection with others” (Sesan, 2009, p. 235).

Gratitude based interventions have been found to decrease symptoms of dysfunctional eating and body dissatisfaction (Wolfe & Patterson, 2017), as well as depression (Simon, 2016). A recent review has discussed the role of self-compassion as a protective factor against poor body image and eating pathology (Braun, Park & Gorin, 2016). Self-compassion has been found to directly influence the severity of eating psychopathology in EDs (Ferreira, Matos, Duarte &

Pinto-Gouveia, 2014) with the link between self-compassion and disordered eating symptomatology apparent even in non-clinical populations (Tylor, Daiss & Krietsch, 2015).

Several studies have shown low levels of self-compassion and high fear of self-compassion in patients with EDs (Kelly et al., 2014; Kelly & Carter, 2015), which were predictive of treatment

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outcomes (Kelly, Carter, Zuroff & Borairi, 2013). Additionally, practicing self-compassion on a daily basis has been found to reduce maladaptive eating patterns in non-clinical populations (Kelly & Stephen, 2016) suggesting the importance of targeting compassion when intervening with individuals suffering with disordered eating (Kelly et al., 2014).

Having meaning in life has been proposed as a protective factor against EDs and body image dissatisfaction (Góngora, 2014). Although research in the actual meaning in life (from the positive psychological perspective) and its relationship with disordered eating is very limited, a large amount of evidence exists to suggest that satisfaction with life is negatively related to a number of symptoms related to EDs, including vomiting, perception of being overweight, binge eating (Matthews, Zullig, Ward, Horn, & Huebner, 2012; Zullig, Pun, &

Huebner, 2007), dieting and laxative use (Esch & Zullig, 2008; Valois, Zullig, Huebner, &

Drane, 2003), perceived eating control (Greeno, Jackson, Williams, & Fortmann, 1998), and body dissatisfaction (Brannan & Petrie, 2011), in both, clinical and non-clinical populations.

Applying positive psychology for weight reduction and maintenance

The benefits of positive psychology, (namely mindfulness and compassion-based approaches), for the treatment of disordered eating pathology have been well documented in the literature over the last couple of decades (Baer et al., 2005; Heatherton & Baumeister, 1991;

Heffner, Sperry, Eifert & Detweiler, 2002; Safer, Telch & Agras, 2001a, 2001b; Telch, Agras

& Linehan, 2000; Wanden-Berghe et al., 2011). Several studies assessed the effectiveness of mindfulness-based interventions (MBIs) in eating psychopathology, reporting decreases in participants’ tendency to eat in response to their emotions, as well as decreased automatic eating (Alberts et al., 2010; Daubenmier et al., 2011; Niemeier, Leahey, Palm Reed et al., 2012;

Jacobs, Cardaciotto, Block-Lerner et al., 2013). In recent years, research has been increasingly focusing on the possibility of applying MBIs to aid weight loss in individuals with obesity (Dalen et al., 2010; Daubenmier et al., 2011; Mason et al., 2016). In the past 5 years, three

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systematic reviews and two meta-analyses have examined the effectiveness of MBIs on problematic eating behaviours and weight loss. Katterman and colleagues (Katterman et al., 2014) reported improvements in binge eating and emotional eating for nine out of the eleven studies reviewed. Six studies provided some kind of nutrition or energy balance education (Alberts et al, 2010; Dalen et al., 2010; Daubenmier et al., 2011; Kristeller et al., 2014; Miller et al., 2012; Timmerman & Brown, 2012), out of which one study (Timmerman & Brown, 2012) also included behavioural goal-setting and problem-solving to change eating behaviour.

The observed effects on weight loss were mixed but those studies that focused on weight loss as a primary outcome (Dalen et al., 2010; Miller et al, 2012; Timmerman & Brown, 2012) found significant decreases in weight (Table 2.5.).

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Table 2.5. Changes in weight/BMI in the mindfulness intervention groups (Adapted from Katterman et al., 2014).

Study Weight loss specific components Weight/BMI change at

post-intervention

Weight/BMI change at follow-up (weeks since baseline)

Effect size at post-intervention (Cohen’s d) Alberts et al., (2010) Information on “healthy food choices”; performed 1 h of exercise after each

session

-1.9 kg n/a -0.12**

Alberts, Thewissen &

Raes (2012)

None -0.4 kg/m² n/a -0.06

Dalen et al. (2010) General information on nutrition, exercise, calories; encouraged to increase levels of physical activity by 5 – 10 % each week

Not given -4.0 kg** (12 weeks)

Daubenmier et al.

(2011)

2-hour nutrition and exercise information session aimed at “moderate weight loss” -0.06 kg n/a -0.02

Kearney et al. (2012) None +0.8 kg +1.2 kg* (24 weeks) +0.04

Kristeller & Hallett (1999)

None No change No change Not given

100 Kristeller et al. (2014) Weight management information briefly introduced in session 4 in the context of

hunger and energy balance; reinforced in session 9 but was not a primary focus of the intervention

-0.1 kg/m² +0.4 kg/m² (28 weeks) -0.01

Miller et al. (2012) Basic information on energy intake and nutrition; encouraged to engage in

Miller et al. (2012) Basic information on energy intake and nutrition; encouraged to engage in