Positive Psychology: Helping Your Patients Make Lasting Behavioral Change
Jennifer Kaltunas, ND, LAc
This article is intended to provide guidance on techniques for empowering our patients to make lasting changes that lead to feelings of improved self-efficacy and happiness. The steps and suggestions discussed below aim to help our patients do this through a combined practice of: shifting the mindset from a negative to a positive filter, developing healthy habits, and strengthening will power. The techniques outlined are derived from the discipline of positive psychology, developed by studying the traits of happy and successful people.1 Combining these techniques with improving physiological foundations will optimize patient outcomes.Patients suffering from mental illness often approach us with deep-seated belief patterns regarding their identity and interpretations of the world that can manifest physically in the body. As naturopathic doctors, we have many tools that support people with mental health disorders, such as amino acid and nutrient therapy, epigenetic support, correction of hormonal imbalances, restoration of gut health, detoxification, homeopathy, herbal and physical medicine. These methods are quite foundational to our treatment strategies; however, they often only get us so far. In addition, patients are often unable to find the motivation to make the changes needed to improve their health. We are not psychotherapists and I do not imply that we should be. However, one of our naturopathic principles is “doctor as teacher.”
This process starts with the first visit. Oftentimes, this visit is focused on what is wrong. Although this is an important aspect of being a good diagnostician, it is equally important to elucidate what is working. Most medical treatment of mental illness is to support patients by eliminating suffering, which is a very worthy goal. However, it takes a whole different set of skills to support our patients to achieve happiness. In order to fill this gap in the doctor-patient relationship, I propose incorporating techniques that equally highlight the good in addition to the bad. See Table 1 for a conceptual intake form that will practically support your patients in this process. This will begin the process of shifting to a positive mental filter from the moment they walk through the door. In addition, it can reinforce their sense of commitment and save time extracting this information during the visit.
The human brain is biased neurochemically towards negativity. This artifact of negative thinking likely carried over from our ancestors who had to constantly be aware of threats to their survival.2 Research shows that the brain reacts strongly to negative stimuli, and shows little response to positive stimuli that pose no threat to our survival.3 Rumination on negative belief patterns can lead to hopelessness and the pitfalls of a “fixed” mindset. With a fixed mindset, patients may uphold and defend the belief that they cannot make meaningful positive change or heal, so their outlook becomes a self-fulfilling prophecy. We can gently guide our patients towards having a “growth” mindset – one in which they transition from being a passive victim towards an active agent of positive change in their lives.
One of the principles in this transition is choosing a growth-oriented identity, focused on positive and attainable goals, rather than a perceived identity itself. One example might be to change the outlook “I want to be a happy and healthy person,” to “I’m taking steps toward a happy and healthy life.” The first outlook can be daunting and challenging to fulfill, since it projects a comprehensive lifestyle change, which may be too vague and intangible. Choosing a goal based on the continued process of positive changes allows one to feel success at all stages along the journey, as well as more freedom to make mistakes.
New research on stress shows that a patient’s own belief in how stress affects him or her results in different health outcomes. In the Whitehall II prospective cohort study,4 individuals who perceived certain stressors as negative influences on their health were twice as likely to suffer from a coronary incident than those who reported/believed that the same stressors did not negatively affect their health. If we believe stress is bad, we are more likely to suffer illness as a result. This provides more evidence for promoting a positive filter on stress for our patients.
Another way to combat negative bias has been demonstrated in the research of Barbara Fredrickson, which indicates that an individual’s positive emotion must outweigh negative emotion by a ratio of 3:1 in order to promote a flourishing mental health pattern.5 When your patients appear stuck in a negative thinking pattern, gently remind them that this is completely natural, and with practice can be changed.
We can encourage our patients to explore positive interpretations of their illness and hardships, to discover the potential silver linings and silent gifts of their circumstances. There is a growing body of evidence which documents that the practice of acknowledging and expressing gratitude is a powerful way to reframe physical and mental well-being. Robert Emmons, PhD, gratitude researcher, summarizes the many benefits of gratitude to include: increased capacity to handle stress, reduction of toxic emotions, improved self-esteem, strengthening social resources, increased ability to access positive memories, and a greater attainment of personal goals.6 Additional research has shown that graduate students practicing gratitude journaling before bed decreased bedtime worry and increased restful sleep.7 For individuals with post-traumatic stress disorder (PTSD), a gratitude disposition was related with improved self-esteem, motivation, and other positive affects.8 The Gratefulness Questionnaire-6 is a great assessment tool to give your patients, in addition to the PHQ-9, to determine their propensity towards a gratitude disposition.9 Simple exercises to implement the practice of gratitude include gratitude journaling, verbally expressing thanks to another person for simple acts, or writing a letter expressing gratitude to someone who has made powerful impact in the person’s life.
Exercises for a Positive Mindset
A list of exercises to promote a positive mindset include:
- Reframing the “bad” exercise. Write a personal story from the negative perspective. Then rewrite it again while looking for the silver linings.
- Gratefulness journaling at least 3 times a day for 1 week
- For every negative thought or action, respond with at least 3 positive thoughts and/or actions
- Start the day with empowering questions and thoughts such as, “What am I excited to do today?” “I look forward to ___ today,” or “What do I get to do today?” (instead of “I am dreading this day” or “ I have no energy for this.”)
- Display reminders of positive achievements
- Practice postures to improve mood: power poses, smiling, laughing
- Practice meditation and deep breathing
- Habits and Will Power
Evolutionarily, humans developed the ability to form habits, or automatic behaviors. This allowed us to free our brain from having to continually focus our will power on every task at hand, which would be energy-consuming and overwhelming. Habits can serve us in this way, but often can become detrimental to our health when they involve unhealthy behaviors, thoughts, and addictions. Success at altering detrimental habits (including addictions) and building healthy habits starts with strengthening will power, which is a skill that can be learned and practiced. Training in self-compassion is a powerful step toward increasing will power. This has been demonstrated in a study in which individuals with binge-eating disorder who were taught self-compassion techniques resulted in fewer binge-eating behaviors compared to controls.10 Also along these lines, relapsed alcoholics who displayed signs of self-shaming were more likely to relapse again.11 The process of behavioral change is challenging, and we must remind our patients to give themselves permission to be human.12
Taking action, even in the midst of fear and anxiety, is likely the most powerful way to strengthen will power. The motivation to change and establish new behaviors and thoughts happens after taking action. It is much easier to change an action then it is to change an emotion or belief. Evidence for the power of action on emotion comes from the research of Carney et al,13 which demonstrated that practicing 2 minutes of power poses each day significantly increased feelings of confidence and behaviors that focused on rewards. These changes also resulted in increased testosterone and lowered cortisol. This research reinforces that the mind and neuroendocrine system will align positive emotions with healthy behaviors.13 Additional examples of behaviors and activities that lead to similar positive physiological response emotions include smiling,14 laughing,15 and deep breathing exercises.16
Goal-setting is a powerful way to provide structure and direction for will power. For optimal outcomes, choose goals that are achievable, measurable, meaningful, process-oriented, and align with a chosen identity.17 Goal-setting techniques in the process of changing unhealthy habits include:
- Undertaking 1 significant change at a time, until it becomes a habit
- Making an old behavior 30 seconds less convenient, and making a new behavior 30 seconds more convenient
- Starting with changes that are small and slow, but trying to do it every day, even if only for 1 minute
- Creating a ritual of the new behavior: do it at the same time and place each day, or pair it with a routine sensory or visual cue
- Pairing a new desired habit with a habit that is already a ritual
- Electing to change a “keystone” habit, which may shift other unhealthy habits along with it
- Changing the environment to match the new goal, including removing distractions (eg, removing drugs and other negative influences from the home, no longer driving by familiar bars)
- Leaving positive and helpful visual reminders (eg, notes on your computer, bathroom mirror, car visor, and inspirational pictures)
- Spending time with people who share the new habit
- Locating resources that reinforce your new habit (eg, books, videos, podcasts)
- Tracking efforts
- Writing down goals
- Giving oneself a reward after completing the new habit
- Taking micro-breaks, such as a 30-second break to let the mind focus on nothing or just 1 thing (eg, breathing, a candle, a tree, music)
A positive mindset and will power are skills that can be learned and practiced. These skills help set up our patients for being active agents in the success of their health journey, despite the inevitable obstacles and setbacks. As they start to see that they can make positive change and shifts in their lives, this will help improve their independent self-esteem, which is not dependent on others but based on their own intrinsic values. It will also help to reinforce a new belief that they can change, grow, and heal, based on their own choices and behaviors, and reduce dependence on us, the practitioners.
Table 1. “Taking in the Good” – Intake and Consent Form
|Whom do you collaborate with in your healing process, and/or consider to be part of your personal support team?|
|List ways you participate in your healing process.|
|List successes you have had in your healing process.|
|List obstacles that you have overcome in your healing process.|
|List obstacles you still struggle with and are looking for support with.|
|List 3 things you are grateful for in your life.|
|What are your goals for our work together, in order of importance?|
|I acknowledge that although I am seeking support for my health, I am committed and willing to collaborate in this healing process. This process may involve the practice of shedding thoughts and behaviors that are not serving me, and inviting in possibilities that are meaningful to my personal healing and growth. I acknowledge that healing can be challenging, but I am willing to take the steps needed, with the support of my team, because I am committed to my personal growth. [Signature]|
Jennifer Kaltunas, ND, LAc, is a licensed naturopathic physician and East Asian medical practitioner in the state of Washington. With a special focus on mental health disorders, including teens and pediatrics, she uses a combination of tools from Eastern and Western medicine, functional laboratory testing, positive psychology, mindfulness, and sound healing. She currently practices in Seattle, WA, at her private practice, In Tune Healing Arts, and at the popular Seattle Integrative Medicine clinic. Her passion lies in shifting the mental health care system to be one of collaboration that truly supports the patient to heal.
- Ben-Shahar T. Positive Psychology 1504. Harvard Open Course; 2009.
- Wright R. The Moral Animal: Why We Are, the Way We Are: The New Science of Evolutionary Psychology. New York, NY: Vintage; 1995.
- Smith NK, Cacioppo JT, Larsen JT, Chartrand TL. May I have your attention, please: electrocortical responses to positive and negative stimuli. Neuropsychologia. 2003;41(2):171-183.
- Nabi H, Kivimäki M, Batty GD, et al. Increased risk of coronary heart disease among individuals reporting adverse impact of stress on their health: the Whitehall II prospective cohort study. Eur Heart J. 2013;34(34):2697-2705.
- Fredrickson BL, Losada MF. Positive affect and the complex dynamics of human flourishing. Am Psychol. 2005;60(7):678-686.
- Emmons RA, Mishra A. Why gratitude enhances well-being: What we know, what we need to know. In: Sheldon K, Kashdan T, Steger MF, eds. Designing Positive Psychology: Taking Stock and Moving Forward. New York, NY: Oxford University Press; 2012: 248-262.
- Digdon N,, Koble A. Effects of constructive worry, imagery distraction, and gratitude interventions on sleep quality: A pilot trial. Appl Psychol Health Well Being. 2011;3(2):193-206.
- Kashdana TB, Uswatteb G, Julian T. Gratitude and hedonic and eudaimonic well-being in Vietnam war veterans. Behav Res Ther. 2006;44(2):177-199.
- McCullough ME, Emmons RA, Tsang J. The grateful disposition: A conceptual and empirical topography. J Pers Soc Psychol. 2002;82(1):112-127.
- Kelly AC, Carter JC. Self-compassion training for binge eating disorder: a pilot randomized controlled trial. Psychol Psychother. 2015;88(3):285-303.
- Randles D, Tracy JL. Nonverbal displays of shame predict relapse and declining health in recovering alcoholics. Clin Psychol Sci. 2013;1(2):149-155.
- Loper C. Permission to be Human. September 26, 2015. Northwest Educational Services. [Blog]. Available at: http://www.nwtutoring.com/2015/09/26/permission-to-be-human/. Accessed November 14, 2015.
- Carney DR, Cuddy AJ, Yap AJ. Power posing: Brief nonverbal displays affect neuroendocrine levels and risk tolerance. Psychol Sci. 2010;21(10):1363-1368.
- Frank MG, Eckman P. Physiologic Effects of the Smile. Directions in Psychiatry. 1996;16(25):1-7.
- Tugade MM, Fredrickson BL, Barrett LF. Psychological resilience and positive emotional granularity: examining the benefits of positive emotions on coping and health. J Pers. 2004;72(6):1161-1190.
- Philippot P, Chapelle G, Blairy S. Respiratory feedback in the generation of emotion. Cogn Emot. 2002;16(5):605-627.
- Locke EA. Motivation through conscious goal setting. Appl Prev Psychol. 1996;5:117-124. Available at: http://expand.nu/wp-content/uploads/M%C3%A5ls%C3%A6tning-review.pdf. Accessed November 14, 2015.