Positive psychology into health-related quality of life research

Integrating positive psychology into health-related quality of life
Crystal L. Park
Accepted: 5 December 2014 / Published online: 14 December 2014
Springer International Publishing Switzerland 2014
Purpose Positive psychology is an increasingly influential force in theory and research within psychology and
many related fields, including behavioral medicine, sociology, and public health. This article aims to review the
ways in which positive psychology and health-related
quality of life (HRQOL) research currently interface and to
suggest fruitful future directions.
Methods This article reviews the basic elements of
positive psychology and provides an overview of conceptual and empirical links between positive psychology and
HRQOL. The role of one central aspect of positive psychology (meaning) within HRQOL is highlighted, and
unresolved issues (e.g., lack of definitional clarity) are
Results Some research on HRQOL has taken a positive
psychology perspective, demonstrating the usefulness of
taking a positive psychology approach. However, many
areas await integration.
Conclusions Once conceptual and methodological issues
are resolved, positive psychology may profitably inform
many aspects of HRQOL research and, perhaps, clinical
interventions to promote HRQOL as well.
Keywords Positive psychology Health-related quality
of life Meaning in life
Positive psychology as a distinct subdomain of psychology
was originally staked out by Martin Seligman in 1998 [1].
In a subsequent landmark paper, Seligman and
Csikszentmihalyi [2] exhorted psychologists to broaden
their vision from ‘‘preoccupation only with repairing the
worst things in life to also building positive qualities.’’
(p. 6). They defined positive psychology as using psychological theory, research, and intervention techniques to
understand the positive, adaptive, creative, and emotionally
fulfilling aspects of human behavior [2]. More recent definitions of positive psychology emphasize ‘‘the scientific
study of optimal human functioning’’ [3] and ‘‘the scientific study of the qualities and conditions that permit
humans to live a life worthwhile’’ [4].
Although Seligman originally focused explicitly on
happiness, his more recent formulation reaches beyond
‘‘happiness’’ to the broader concept of ‘‘well-being,’’ which
he terms ‘‘flourishing’’ [5]. According to Seligman’s recent
formulation of positive psychology, well-being (i.e.,
flourishing) arises from successful pursuit of five endeavors
or pillars: Positive emotions, Engagement, Relationships,
Meaning, and Achievement [5]; see Fig. 1]. Together,
these five pursuits comprise his PERMA model. Positive
emotions involve feeling good, happy, and satisfied; specific positive emotions include pleasure, rapture, ecstasy,
warmth, and comfort. Engagement involves being completely absorbed in activities, experiencing the sense of
flow [6]. Relationships in Seligman’s PERMA model [5]
refer to being authentically connected to other people.
Meaning involves a sense that one’s existence is purposeful; although meaning is often framed within religion or
spirituality, it does not have to be [7]. Achievement in the
PERMA model refers to a sense of accomplishment and
success in one’s pursuits.
Seligman proposed that each element contributes to
well-being; each is defined and measured independently of
the others. According to Seligman, these five elements are
‘‘the best approximation of what humans pursue for their
C. L. Park (&)
Department of Psychology, University of Connecticut,
Box 1020, Storrs, CT 06269, USA
e-mail: [email protected]
Qual Life Res (2015) 24:1645–1651
DOI 10.1007/s11136-014-0889-z
own sake’’ [5, p. 97]. Seligman argues that one’s perception
of the extent to which he or she experiences these five
PERMA pillars determines his or her sense of flourishing
While the PERMA model is the predominant model
within positive psychology, with an explicit focus on the
experience of a ‘‘good life,’’ happiness or flourishing, other
leading positive psychologists have highlighted highlights
many other positive constructs, such as hope, optimism,
gratitude, character strengths, transcendence, empathy, and
altruism (see [8] for an overview). For example, Fredrickson [9] has promoted the broaden-and-build theory of
positive emotions, while others have proposed the utility of
exploring to distinct aspects of well-being, eudaimonic
(meaningful), and hedonic (pleasurable) [e.g., 10, 11].
Positive psychology is increasingly influential within
psychology and many related fields, including behavioral
medicine, sociology, and public health, but remains relatively unintegrated into the extensive volume of research
being conducted on health-related quality of life (HRQOL).
In this article, I describe how positive psychology and
HRQOL research currently interface, highlight the role of
one central aspect of positive psychology (meaning) within
HRQOL, and address some of the unresolved conceptual
issues in integrating positive psychology into quality of life
Current integration of positive psychology and HRQOL
In recent years, some HRQOL researchers have been
influenced by the positive psychology zeitgeist. For
example, each of the PERMA pillars proposed by Seligman
[5] has been a focus of research in the context of HRQOL,
although some have as yet received relatively little
empirical attention, while others have garnered much more.
Copious research has linked positive emotions with
HRQOL and other aspects of physical health (see [12] for a
review). Few studies have examined how engagement
relates to HRQOL [e.g., 13], but a vast body of research
links aspects of positive relationships, such as satisfaction
and social support, with HRQOL [e.g., 14].
Meaning has been a perennial topic of interest to
researchers, particularly humanistic and existential psychologists, but has only recently been examined in the
context of physical health and HRQOL. Because meaning
is so central to positive psychology and underlies the other
pillars (i.e., the impact of relationships and achievement
are based on their significance to the individual and positive emotions and engagement lead to flourishing only in
the context of meaningful pursuits; [15]), I focus on
research linking meaning in life with health and HRQOL in
the next section to illustrate the ways in which positive
psychology might profitably inform many aspects of
HRQOL research. The last pillar of PERMA, achievement,
has received little explicit research attention in the context
of HRQOL, but related topics such as work productivity
have been studied in this context [e.g., 16]. Further,
achievement is strongly linked with purpose and pursuit of
important goals, which are elements of meaning in life, as
will be discussed below. In addition to the linkages
between the core PERMA pillars and HRQOL, others have
linked HRQOL to positive psychology constructs such as
altruism [17], optimism [18], and gratitude [19]. For
example, in research conducted in a variety of populations,
Schwartz et al. have found that altruistic behaviors appear
to have a positive impact on mental health in both genders
and on physical health in females [see 17 for a review].
Flourishing and the centrality of meaning
As noted above, some psychologists have proposed that
meaning in life is central to flourishing; to live well and
with quality, it is essential that people feel that their lives
matter are understandable and have a transcendent purpose or mission [7, 20]. Meaning in life refers to a sense
of comprehensibility, significance, and purpose [21–23].
Many definitions of meaning in life have been proposed;
although differing in particulars, these definitions converge on the notion that meaning in life involves cognitive, motivational, and evaluative/emotional components
The cognitive component of meaning in life involves a
sense of coherence or comprehension of the world and
one’s place in it [20]. The motivational component refers
to a sense of purpose or goal directedness. People have
overarching goals or missions (implicit or explicit) by
which they organize their lives; the extent to which they
perceive themselves as living in alignment with and
making progress toward their overarching goals through
their daily experiences contributes to a sense of meaning
in life. Finally, meaning in life has an evaluative/emotional component in terms of perceiving that one’s life
matters and is somehow significant in the broader scheme
of the universe [24]. Thus, meaning in life encompasses a
sense of comprehension, purpose, and mattering [25].
Meaning in life is often, but not always, closely linked
with spirituality [5, 7].
Affect Engagement Relationships Meaning Achievement
Fig. 1 Seligman’s [5] model of flourishing
1646 Qual Life Res (2015) 24:1645–1651
Meaning in life and HRQOL
Myriad studies have reported that a higher sense of
meaning in life is associated with higher levels of physical
and mental health and HRQOL. For example, Peterman
et al. [26] recently analyzed four large datasets drawn from
cancer and HIV/AIDS patients and found substantial and
consistent correlations between meaning and multiple
aspects of mental and physical HRQOL across the samples.
Other studies have found that meaning in life was related to
better self-rated health and HRQOL in a community sample of middle-aged women [27] and in cardiac outpatients
Such linkages with meaning in life are found not only
for subjective assessments such as HRQOL but also for
objective health indices. For example, a 2-year prospective
analysis of the Health and Retirement Survey, a large
nationally representative sample in the USA, found that,
controlling for a large set of potential confounding variables, meaning in life predicted lower rates of subsequent
stroke [29] and myocardial infarction [30]. In a large,
nationally representative sample in Hungary, life meaning
was inversely related to cancer, cardiovascular, and total
premature regional mortality rates, findings that held after
controlling for gender, age, and education [31].
As important as a sense of meaning in life appears to be
for everyday well-being, it may be particularly important to
people when they are facing sickness or disability and thus
may be especially critical for HRQOL. Myriad studies have
documented that higher levels of meaning in life are
associated with better self-rated health and HRQOL in
medical populations [27], including in those living with
serious illnesses such as cancer [32] and heart failure [33].
Meaning in life has been positively related to rate of
recovery from knee surgery [34] and to higher mental and
physical HRQOL, as well as less pain and fatigue, in
rheumatoid arthritis patients [35].
Meaning influences HRQOL through multiple
Relations between meaning in life and HRQOL may be
mediated by multiple pathways, as illustrated in Fig. 2.
First, health behaviors may be an important pathway of
influence. Studies have demonstrated that people with a
deeper sense of meaning in life tend to adopt more beneficial health behaviors. For example, in a large sample of
undergraduate students, meaning in life was positively
associated with a range of beneficial health behaviors
including exercising, nutritious eating, and avoidance of
tobacco [36]. Meaning in life has been related to the performance of health-promoting activities in many samples,
including Anglo women (but not Hispanic women) [37],
Japanese adults [38], and cardiac outpatients [28]. The
reason for this linkage may be straightforward: People with
more reasons for living and more satisfying life purposes
may more strongly desire to keep on living; one way to do
so is to practice good health behaviors. However, such an
explanation awaits empirical validation.
Second, meaning in life may also affect physical health
directly through several different physiological processes.
In experimental studies, higher levels of meaning in life
were related to better autonomic nervous system functioning [39] and to lower mean heart rate and decreased
heart rate reactivity [40]. In addition, life meaning was
associated with lower aortic calcification in a community
sample of middle-aged women [41] and to lower blood
pressure in a community sample of people living in Chicago [42]. In a study of breast cancer patients, having a
higher sense of meaning in life was related to subsequent
increases in natural killer cell cytotoxicity, an important
marker of successful immune functioning [43].
A third pathway through which meaning in life may
influence health and HRQOL involves its coping and
stress-buffering functions. For example, in a nationally
representative sample of older adults, a strong sense of
meaning in life buffered the impact of traumatic life events
on depressive symptoms [44]. Having a strong sense of
meaning and purpose provides people dealing with health
conditions and illness a resource that is helpful in coping
with the stressors they encounter; this sense of meaning
and purpose is often expressed through transcendent spirituality or religiousness [7]. Coping that involves religiousness or spirituality has been shown to be very helpful
in improving the mental and physical well-being of people
dealing with many types of health problems, including
cancer [45] and HIV [46].
Advancing the integration of positive psychology
in HRQOL research
Positive psychology is a broad subfield that encompasses a
variety of different constructs, many of which may usefully
inform and further HRQOL research. However, lack of
in Life
Health Behaviors
Processes (e.g., ANS,
Health &
Fig. 2 Pathways through which meaning affects health and HRQOL
Qual Life Res (2015) 24:1645–1651 1647
conceptual clarity currently limits research progress.
Advances in integrating positive psychology and HRQOL
research will require careful attention to conceptualization
of each. One broad conceptual issue is how positive psychology squares with HRQOL. Most research explicitly
conducted from the positive psychology perspective has
targeted general population samples, and in fact, many
strictly positive psychology-focused researchers steer clear
of illness-related functioning because it is not entirely
‘‘positive’’ (i.e., it occurs in the context of sickness) [47].
Because HRQOL by definition refers to ‘‘the functional
effect of a medical condition and/or its consequent therapy
upon a patient’’ [48], linking positive psychology and
HRQOL research requires some broadening of scope for
Further, assessment of HRQOL has traditionally focused
on bothersome symptoms or decrements or deviations from
a normal level of functioning and well-being rather than on
the possibilities of thriving or doing better than a baseline
or better than expected [49]. Some researchers have
recently suggested that quality of life (QOL) research
should encompass the positive dimensions of functioning
and well-being rather than focusing solely on decrements
[e.g., 4, 50].
However, HRQOL is a specific subset of QOL that
pertains to disability, illness, or pathology [51]. HRQOL
research that integrates or focuses on positive aspects of
well-being or that includes assessment tools that measure
deviations of normal in the positive direction remains rare
[51]. The enormously popular post-traumatic growth or
benefit-finding research has been suggested as a way to
incorporate a positive psychology perspective on illness
[52], but the validity of this constructs remains undemonstrated and its value unclear [53, 54].
A related conceptual issue pertains to the ultimately
desired goal state of positive psychology, which is often
referred to as happiness [55]. Happiness has tremendous
popular currency [56], but its imprecision has led some to
reframe or rename the ultimate desired state from the
perspective of positive psychology. Seligman [5] has settled on the term flourishing, defined as having adequate
amounts of the five PERMA pillars in one’s life. Further,
the five pillars are likely to have a fair amount of conceptual and operational overlap, further complicating
efforts to study their individual contributions to flourishing.
At this point, it appears that flourishing is a conceptually
useful concept but remains too operationally fuzzy to be
useful in advancing research [4].
Another thorny conceptual issue is the extent to which
the PERMA pillars form the conditions under which
someone will experience a desired state such as flourishing
or happiness, versus the extent to which these pillars
comprise desirable states in and of themselves. For
example, Seligman [5] describes the engaged life as one in
which individuals experiences flow by being thoroughly
invested in and following their pursuits (e.g., being one
with the music, lack of awareness of the passage of time,
full absorption in activities). For some, that flow state may
in fact constitute the desired endstate [6]. Similarly, people
who spend their lives in deeply meaningful pursuits such as
spiritual communion or service to others may consider
meaning in life to be the ultimate state that they seek. This
issue is important in light of the recent attention given to
patient-centered outcomes. For many people, both those
with and without serious health issues, meaning in the form
of spirituality or transcendence constitutes their ultimate
desired state [7, 57] rather than being a pillar leading to
some other state.
Conceptualizing positive psychology concepts such as
meaning and spirituality as predictors or as desired outcomes matters, because this conceptualization determines
the questions researchers ask and the methods they use to
ask them. The lack of clarity on this issue has led to a
plethora of research that conflates predictors and outcomes
within the same study, producing results that are impossible to interpret. Some of the work on meaning and spirituality provides a prime example. As noted above, meaning
and spirituality are often very important in the context of
disease—a resource and part of the coping process in
which people engage to deal with their illness. However,
their spiritual lives are also a domain of well-being about
which they care deeply, although most standard measures
of HRQOL do not include spirituality. Thus, many studies
have included the FACIT-Sp [58], which was designed to
assess spiritual well-being, to complement other FACIT
scales that tap into other aspects of HRQOL. However, the
FACIT-Sp is often conceptualized as a predictor of
HRQOL [59]. Such studies essentially show that spiritual
well-being predicts other aspects of well-being.
Many psychometrically sound measures of positive
psychology constructs are available for use by researchers.
Once they are clear on the conceptualizations on which
they will rely in their research, researchers should deliberately attend to the specific constructs assessed by various
measures and select with care so that they are certain that
the specific elements of positive psychology and HRQOL
in which they are interested are those they are in fact
assessing. One set of measures gaining popularity is the
NIH Toolbox [60], a set of brief multidimensional measures assessing cognitive, emotional, motor, and sensory
function designed to serve as a standard that can be used as
a ‘‘common currency’’ across diverse study designs and
settings. Among measures recently added to the Toolbox
are those for psychological well-being (positive affect, life
satisfaction, and meaning and purpose) [61]. Many similar
measures are available and warrant consideration.
1648 Qual Life Res (2015) 24:1645–1651
Among the interesting questions awaiting future
research are how different constructs within positive psychology, such as the five pillars, differentially relate to
different aspects of HRQOL, and the mechanisms through
which these different elements may influence health and
HRQOL. Such research will surely benefit from efforts to
more clearly conceptualize and measure positive psychology constructs as well as from a thoughtful consideration
of the desired ultimate goals or states of patients, an inquiry
being made more prominent with the emphasis on patientcentered outcomes.
Clinical applications
Positive psychology opens new avenues for clinicians
interested in improving HRQOL in the context of many
health conditions and illnesses [52, 62]. One promising
approach taken by positive psychologists is to assess and
then build on individuals’ strengths, based on the notion
that greater reliance on one’s highest strengths will lead to
the experiencing of more positive emotion, engagement,
meaning, positive relationships, and accomplishment and
therefore flourishing [63]. A framework of strengths and
methods for assessing them has been developed by positive
psychologists (the Virtues in Action Inventory, measuring
character strengths; [64]), but clinical interventions based
on this scheme are quite early in their development [62].
Currently, the most widely used set of interventions
derived from positive psychology are those focused on
gratitude. Clients are encouraged to increase their sense of
gratitude through techniques such as contemplating their
blessings, making gratitude lists or diaries, and enacting
behaviors expressing their gratitude, such as by writing a
letter of thanks to an important person in their lives and
reading the letter aloud to that person. Studies of the impact
of gratitude interventions suggest that they are effective in
improving well-being, although the research methodology
of these studies is weak and findings should be regarded as
preliminary [see 62].
To date, little clinical research from a positive psychology perspective has yet been conducted, and of that,
very little on groups living with life-limiting or chronic
illnesses. In addition, most of the research that has been
conducted has not been methodologically rigorous. Further,
some question the extent to which increasing happiness or
flourishing is possible, given people’s inherent tendency to
readjust to baseline levels of well-being [e.g., 65]. Clearly,
much additional research is necessary before clinical
interventions based on positive psychology are ready for
application to improve HRQOL in these groups. Yet such
approaches remain promising. Understanding more about
how to help people to successfully pursue PERMA
elements such as positive emotions, relationships, and
meaning may indeed lead to increases in flourishing and,
presumably, in the context of health or medical conditions,
HRQOL as well.
Positive psychology was developed to complement mainstream psychology’s then-current focus on pathology,
encouraging psychologists to include a focus the more
aspirational aspects of being human [66]. Perhaps a similar
development will occur as positive psychology and
HRQOL are increasingly integrated: positive psychology
may usefully help HRQOL researchers expand their focus
from one primarily on deficits and impairments vis-a`-vis a
baseline or normative functioning to also consider the more
positive ends of HRQOL.
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