Positive Psychology and Hope as Lifestyle Medicine Modalities in the Therapeutic Encounter: A Narrative Review

Abstract

The majority of deaths in the United States are attributable to lifestyle-associated chronic diseases. Therapeutic encounters must now routinely address lifestyle-related behavior changes and promote patients’ active involvement in self-care and chronic disease management. Positive psychology has been recognized in the realm of lifestyle medicine for its potential applications in effecting patient behavior change. One notable framework within positive psychology that is well suited for facilitating specific behavior changes is hope theory, which can be used to elicit change talk and build agency among patients with chronic diseases. This review explores key literature in positive psychology and hope theory and its practical applications to direct patient care, which includes an illustrative case study. There are still many unexplored intersections of health-related variables and hope. The cognitive framework of hope theory lends itself well to a broad range of situations, including brief ambulatory encounters. Clinicians will be instrumental in increasing our understanding of how hope theory can be applied to the therapeutic encounter. There are simple and efficient ways to innovate in this area. Having information about a patient’s hope has the potential to make empathic connections easier and create opportunities to ask specific questions to help patients overcome barriers.

‘. . . it is imperative that therapeutic encounters leverage hope for improvement, address health behavior changes, and promote patients’ active involvement . . .’

Current trends in mortality demonstrate that the majority of deaths in the United States are attributable to chronic diseases, such as cancer and cardiovascular disease, with deep, unmistakable roots in lifestyle factors. ¹ Over time, physicians and other health care providers have moved from frequently treating life-threatening infections and other acute disease processes to employing more prevention and treatment modalities for degenerative and human-made diseases.^1,2 Many of these diseases are caused by unhealthy lifestyle behaviors and environmental factors (eg, poor nutrition, sedentary behaviors, substance abuse, disrupted sleep patterns, lack of positive social relationships, chronic stress, etc). Fortunately, approximately 80% of chronic diseases are preventable with the modification of these unhealthy lifestyle behaviors. ² Therefore, it is imperative that therapeutic encounters leverage hope for improvement, address health behavior changes, and promote patients’ active involvement in self-care and chronic disease management. ³

Unfortunately, getting patients more involved in self-care and chronic disease management is often more difficult and complex than simply educating and counseling patients. Motivational interviewing and other evidence-based methods for encouraging health behavior change can effectively support patients in achieving positive outcomes.^4,5 Research conducted on motivational interviewing demonstrates its broad applications and how it can be combined with other methods to promote behavior change. More recently, positive psychology has been recognized for its potential application in effecting patient behavior change. Therefore, the purpose of this narrative review is to explore how positive psychology and motivational interviewing elucidate hope and can inform clinical practice to promote optimal health outcomes for all patients.

Positive Psychology and Lifestyle Medicine

Positive psychology offers a different perspective on the issue of encouraging patients to change lifestyle-related health behaviors. While the traditional fields of clinical psychology and psychiatry have focused on labeling and treating aberrations within the individual that limit functioning as evidenced by the Diagnostic and Statistical Manual of Mental Disorders (DSM), positive psychology seeks to discover, define, and nurture normal psychological traits and qualities that promote flourishing.^6,7 Martin Seligman, one of the pioneers of positive psychology, argued that psychological well-being and happiness are derived from 5 core elements described in his “PERMA” model: positive emotion, engagement, relationships, meaning, and accomplishments.^6,8 This model is a useful framework for the provision of lifestyle medicine because it captures and defines psychosocial factors that may not be apparent to the busy clinician but are of clinical importance. Furthermore, studies on the PERMA model within the context of lifestyle medicine have demonstrated that supporting positive emotion and the other elements as much as possible is associated with better health outcomes, including cardiometabolic risk and hemoglobin A1c control. ⁹

Clinicians can ask questions framed around the 5 elements of the model in order to determine if patients have specific barriers to flourishing and open up dialogues with patients that have the potential to maximize their willingness to modify unhealthy behaviors (Table 1). Researchers have developed a PERMA profiler that generates easily interpretable scores for all 5 elements plus a domain relevant to health. ¹⁰ This profiler is available for free online and can be integrated into standard intake questionnaires used routinely by different practices. ¹¹ It is one of many examples of well-studied topics that lend themselves appreciably to clinical medicine, particularly at the intersection of lifestyle medicine.

Table 1.

Example Questions That Clinicians Can Ask Patients in the Context of Seligman’s PERMA Model.

PERMA Element	Example Questions for Patients
Positive Emotion	• How often do you feel like life is going well? • Do you feel satisfied with life?
Engagement	• How often do you lose track of time with the things you are doing? • How often do you feel excited about the things you do regularly?
Relationships	• Do you feel that you receive adequate support from others? • To what extent are you satisfied with your personal relationships?
Meaning	• Do you feel that you lead a meaningful life? • How often do you feel your life is heading in the right direction?
Accomplishments	• How often are you able to get things done that you set out to do? • How often do you feel that you are making progress toward your goals?

Whether one is looking at individuals or entire populations, positive psychology aims to elucidate eudaimonia, or flourishing, which is defined as optimal living based on one’s values, happiness, interests, important relationships, and sense of meaning.^6-8 Ideally, everyone would be able to achieve a eudaimonic life; however, many Westernized countries—including the United States—are moving away from this ideal. Worldwide research on happiness has shown that people living in the United States have become increasingly unhappy in recent years, moving down 0.315 points on a 10-point Likert-type scale between 2008-2010 and 2015-2017. ¹² One possible explanation for this is that many individuals do not have the resources or support to attain fulfillment and establish meaning in their lives.^12,13 Moreover, increases in environmental stressors and systemic rigidity have sufficiently distracted many people from their senses of purpose.^3,6,12

This situation poses an issue for clinicians and patients alike because optimal living is associated with a number of different adaptive and health-benefiting outcomes, such as lower rates of chronic stress.^14,15 Persistently high levels of psychosocial stress can contribute to and sometimes precipitate chronic disease states and negative health outcomes, including major depression, cardiovascular disease, and immunosuppression. ¹⁶ Therefore, health care providers addressing psychosocial stressors and associated health behaviors may help to alleviate the chronic disease burden. How can clinicians use positive psychology techniques to foster a strong patient-provider relationship and promote better health outcomes?

One answer lies in positive psychology-geared interventions.^6,7 There is a growing body of evidence that supports various positive psychology-based approaches as methods by which to achieve better health outcomes, including common chronic diseases. For example, a meta-analysis of randomized controlled studies consisting of interventions grounded in positive psychology, including self-help, group training, individual therapy, and other modalities, revealed significant increases in subjective well-being and significant decreases in depressive symptoms. ¹⁷ In the context of type 2 diabetes, a combined positive psychology and motivational interviewing intervention consisting of guided exercises and goal-setting activities produced improvements in adherence to health behaviors and overall self-care. ¹⁸ A preliminary randomized trial based on positive psychology for patients who recently underwent a procedure for cardiac disease treatment revealed that patients receiving the intervention reported significant improvements in happiness, depression, and hope, all of which are linked to better long-term cardiac outcomes. ¹⁹

Hope Theory: An Important Concept in Positive Psychology

The field of positive psychology is vast and encompasses many different psychological traits and factors that are associated with flourishing. Thus, many types of interventions can be developed through this orientation. One notable framework that is well suited for promoting specific behavior change is hope theory, which can be used to elicit change talk and build agency among patients with chronic diseases. ²⁰ Much of what has been published in the medical literature on hope theory has included several different patient populations, such as patients with cancer, mental disorders, or spinal cord injuries.^21,22 Emerging literature is beginning to show that hope theory has a place in community settings for all people, regardless of psychopathology or physical impairment.

Based on the works of Charles “Rick” Snyder and his colleagues, hope theory centers on the processes and outcomes of goal-oriented thinking and how this thinking leads to dispositional hope.^20,23 This means that higher levels of hope are associated with a stronger inclination for goal setting and attainment (eg, following a discharge plan or adhering to lifestyle change recommendations) while lower levels suggest increasing despair and subsequent apathy when contemplating goals.^20,24 As we strive toward our goals, we tend to think constantly about what we are doing and how we are going to move from one point to another, making the process of goal pursuit cognitive in nature.^20,24 Individuals with high educational attainment tend to have higher hope as a result of their history of goal attainment. ²⁵ Thus, clinicians tend to be high-hope individuals. On the other hand, some patients may not share this level of hope; some may have a low level that limits their ability to identify and achieve goals and make necessary health-related changes. Snyder’s hope theory is based in cognition rather than emotion, which means interventions can tackle augmenting hope through activities that affect thinking patterns.^21,24 This distinction is important because the cognitive foundation of hope means that there is an intrinsic logic of the process that leads from setting a goal and then pursuing it whereby affective responses arise from one’s success or failure in achieving one’s goals but are not necessary to the process of goal pursuit.

Hope theory indicates that there are 2 principal ways of thinking about a particular goal: pathways thinking and agency thinking.^20,23,24 A conceptual summary shows how agency and pathways thinking interact to produce overall hopeful cognitions (Figure 1). Pathways thinking is the act of appraising the availability or unavailability of resources and routes necessary to attain a goal. ²⁰ This is often defined as the external driver of goal-directed action because it pertains to what lies outside of the individual in the environment. On the other side, there is agency thinking, which is one’s perceived capability of and motivation for achieving a desired goal. ²⁰ Since this way of thinking relates to the individual independent of external factors, it is considered to be an internal driver of this process. Both positive appraisal of resources and routes (ie, pathways thinking) and positive appraisal of oneself (ie, agency thinking) are imperative for having high levels of hope when one is going after a goal.^20,24

Figure 1.

Conceptual summary of hope theory (adapted from Handbook of Positive Psychology ²⁸ ).

Humans are a goal-driven species, and our ability to set and pursue goals is a major determinant of our future well-being.^26,27 A large part of this association can be attributed to the fact that goal-oriented thinking typically reinforces a person’s sense of purpose in life and, thus, provides a solid foundation for changing behaviors and investing energy in actions that can benefit his or her health and happiness.^24,26-28 When a major pathway leading to an important goal is blocked, humans go through a process of “grieving” the loss of a goal, beginning with rage and proceeding to apathy. ²⁹ This process can be thought of as a sequence of decreasing hope and changing emotional responses (Figure 2). The drive to attain goals in order to change something about oneself or one’s environment is ingrained in our instinctual drive toward survival because achieving certain goals can enhance an individual’s fitness. ²⁸ Expanding on this idea, Snyder described all purposeful human action as goal directed because humans expect to make progress toward their ultimate goals when they invest their energy.^20,21,24

Figure 2.

Pathway blockage sequence (adapted from C.R. Snyder’s Psychology of Hope: You Can Get Here From There ²³ ).

Applications of Hope Theory in the Therapeutic Encounter

Since we all have goals that are important for our overall well-being, we can all benefit from understanding and working to maximize our own hope as well as the hope of others. Whether someone is a patient or a clinician, that person brings different perspectives, knowledge, motivations, and goals to each and every clinical encounter. Not every patient will have the same health goals even if they have the same conditions, and some may not understand how some types of health care tie in with their larger goals and sense of purpose. For others, traumatic events in adulthood, adverse childhood experiences (ACEs), and even chronic stress could stymie goal-focused thinking, particularly as it applies to their health.^30-32 Lifestyle medicine, which aims to treat chronic disease, depends on health behavior change, which in turn can be enhanced through positive psychology approaches, such as hope theory.

All patients need clinicians who are capable of seeing the bigger picture of their health by taking into account how past experiences influence future decisions. The bigger picture in this context means the psychosocial determinants of their health that lie outside of the traditional biomedical framework. We argue that a hope-informed approach is instrumental for achieving more successful therapeutic encounters, which might offer mutual benefits to both patients and clinicians. Several studies help illustrate this point. For example, researchers have found that higher levels of hope are associated with lower reported rates of suicidal ideation. ³³ A different group found that there is a differential effect of high trait hope and low trait hope on suicidal behavior as a function of depression whereby hope significantly lowers suicidal behavior with rising depression scores. ³⁴ Another group of investigators, including Snyder himself, discovered that high levels of hope in children were a significant predictor in asthma treatment adherence. ³⁵ Related to clinician well-being, one study of general pediatricians revealed that high agency thinking buffered against the effects of obstacles in enrolling patients in an asthma management program, even after controlling for self-efficacy and conscientiousness. ³⁶

In thinking about levels of hope, a crucial question emerges: How does one measure hope? Over the years, a number of different psychometric scales have been developed and tested, with several being designed to measure “hope” in specific populations like patients with cancer. ²² The most commonly used of these scale is the Adult Hope Scale (AHS), which was the first assessment tool that Snyder created in the context of hope theory. ²⁰ The AHS contains 12 items using an 8-point Likert-type scale: 4 items related to pathways thinking, 4 items related to agency thinking, and 4 “filler” items. ²⁰ For example, the item “My past experiences have prepared me well for my future” measures agency thinking, and “There are lots of ways around any problem” measures pathways thinking. ²⁰ One study demonstrated that the test-retest score reliability was consistently high for the AHS, suggesting that the AHS remains representative and stable across time when it is administered to individuals. ³⁷ In addition to the AHS, there is a version for children known simply as the Children’s Hope Scale (CHS), which is validated for children aged 8 to 16 years. ³⁸

A Closer Look at Using Hope-Based Strategies: Case Study

If a clinician measures hope in his or her patient population, what does the next step look like? While there is no specific empirical evidence to inform clinical guidelines directly, there has been sufficient evidence published to date supporting certain actions, many of which involve simple questions to the patient based on his or her hope score. What is important to keep in mind about hope scores is that they provide insight into a person’s ability to change a behavior, and this exact association is the reason why hope has been studied in the context of cognitive behavioral therapy (CBT). ³⁹ Therefore, measuring hope might be a way to understand why certain patients are less likely to adhere to medical recommendations than others or why some change more rapidly than others over the course of a longitudinal patient-clinician relationship.

We present 2 different therapeutic encounters that can take place between a patient and clinician in a common clinical case scenario that illustrates patients’ responses to their treating clinicians based on their relative levels of hope. The case is as follows:

A 47-year-old African American woman with metabolic syndrome presents to your clinic for a follow-up visit to discuss medication adjustments. She is currently taking metformin, hydrochlorothiazide, enalapril, and simvastatin for chronic disease management. Despite taking her antihypertensive medications regularly, her blood pressure remains elevated. During previous visits, she was counseled to limit her daily sodium intake because of her high intake of fast food and frozen meals. You ask the patient how successful she feels she has been in attaining this goal.

Encounter A: Chronic Disease Management Visit With Low Hope

Patient:

I have been trying to make the changes you told me to make last time, but it has been challenging.

Physician:

How capable do you feel you are in making these changes?

Patient:

I do not feel like I can do it. I’ve been trying to get myself on a healthy diet to get off my blood pressure medications, but I feel like I going nowhere fast.

Physician:

Is there anything that is in the way of you feeling successful?

Patient:

Well, I don’t feel very motivated. After a long day of work, I’m too tired to cook myself a healthy meal at home. It’s much easier to just eat fast food or heat up some of my frozen meals. I know that they are bad for me, but what can I really do?

Physician:

What are some things that can help you feel more motivated?

Patient:

To be honest, I cannot think of anything.

Physician:

Let’s spend some time to think about what resources you have around you to help you feel more motivated and successful at accomplishing your goal.

In this particular case, the patient struggles with adhering to a low-sodium diet. She describes not feeling motivated and instead feeling unsuccessful. Investigation of her hope score reveals that her agency thinking and pathways subscores are on the lower end of the range. The physician also identifies the factors relating to the reduced hope score, such as the patient’s negative, avoidant thinking in the way she perceives herself as being unsuccessful. The patient also expresses issues in the way she is not pursuing and, thus, not meeting her goals. The physician continues to ask the patient questions about her negative self-appraisal and barriers to behavior modification and encourages further discussion about pathways thinking.

Encounter B: Chronic Disease Management Visit With High Hope

Patient:

I have been trying to make the changes you told me to make last time, but it has been challenging.

Physician:

How capable do you feel you are in making this change?

Patient:

I feel like I can do it. I have been able to make some progress so far despite some of the challenges.

Physician:

How motivated are you to adhere to a low-sodium diet?

Patient:

I’m very motivated! I know that I just need to think of some ways to cook more at home even if I am tired after a long day of work.

Physician:

Have you experienced any difficulties in identifying ways to achieve your goals?

Patient:

I have thought of a few ways to get around eating fast food. I could maybe spend one day preparing meals for the whole week or take a different route avoiding fast food restaurants when driving home from work. I can also talk to my husband about helping me around the kitchen.

Physician:

Those are some great ideas on sticking to your goal. It seems like you have the resources and support necessary to make change.

In this particular conversation, the patient also struggles with adhering to a low-sodium diet. However, investigation of her hope score reveals that her agency thinking and pathways subscores are higher than in Encounter A. She appears to be more motivated and recognizes the barriers causing her to not adhere to her diet. She also offers suggestions as to how she can overcome the challenges or barriers to behavior modification. The physician can thus serve a supportive role in encouraging further discussion about pathways thinking and helping the patient to maintain her hope in being successful.

Both conversations in the case show that the same patient can respond differently based on his or her hope level. The case also emphasizes how there may be different responses in the future and shows how measuring hope can be performed in a clinical setting. When discussing health-related behavior change with patients, clinicians can ask specific questions to understand more deeply what factors are affecting their patients’ level of hope, pathways thinking, and agency thinking (Table 2). Apart from direct questioning, clinicians may also consider looking into available hope therapy resources, which is based on hope therapy and walks participants through concrete steps for learning to engage in more hopeful cognition. This may be an exceptional resource for patients with low hope levels who may not amenable to change without the right support for setting goals initially.

Table 2.

Example Questions That Clinicians Can Ask Patients in the Context of Hope Theory.

Hope Theory Construct	Example Questions for Patients
Agency thinking	• How capable do you feel you are in making this change? • How motivated are you to change this behavior? • What do you understand about how this change will benefit your health? • How much success have you had in the past in making a similar change?
Pathways thinking	• To what extent are you supported by others in achieving your health-related goals? • Do you have the necessary resources, including money and transportation, to make the changes we have discussed? • Have you experienced any difficulties in identifying ways to achieve your goals?
Goal setting	• What health-related goals have you set for yourself? • What gives your life meaning? What short-term and long-term goals have you set for your health? How successful have you been in achieving them?

Opportunities for Future Inquiry and Clinical Innovation

While the hope theory literature has expanded markedly over the past 2 decades, there are still many unexplored intersections of health-related variables and hope, which includes high-quality evidence from randomized, controlled trials to show the effectiveness of hope-informed strategies versus traditional patient-clinician interactions. We argue that hope theory is not a concept whose utility in influencing health-related outcomes is limited to special situations only. In fact, the cognitive framework of the theory lends itself well to a broad range of situations, including general community-based applications for public health initiatives and brief ambulatory encounters. More work needs to be done to understand how hope influences patient behavior, which may include topics such as nonadherence to medical recommendations, health care utilization rates, and differential responses to evidence-based counseling techniques like motivational interviewing.

Clinicians will be instrumental in increasing our understanding of how hope theory can be applied to the therapeutic encounter. While we acknowledge that the competing demands of clinical practice may limit how much interested clinicians may contribute to achieving this goal, there are simple and efficient ways to innovate in this area that have sufficient theoretical and practical foundations to support their use. For example, the ready availability of the AHS and CHS makes it possible for clinicians to administer the scales while patients are in the waiting room. The total hope scores as well as the agency and pathways thinking subscores can be used to get an idea of where the patients are at the time of their visits. Having this information about a patient’s goal-oriented, hope-driven energy has the potential to make empathic connections easier and create opportunities to ask specific questions based on a patient’s strengths and capabilities related to making a health behavior change like increasing physical activity or balancing macronutrient and micronutrient intake. Furthermore, if the goal of care is disconnected from the patient’s larger goals, this approach allows the clinician to elicit this information and explore how to set a goal that is more appropriate for the patient.

In considering the case study, many of these questions are similar to what clinicians may already ask during office visits, with the main difference being that the hope-oriented questions take into account a patient’s goal-specific thoughts, goals, and perceived barriers. Clinicians can better assist patients with developing methods on how to improve hope, agency thinking, and pathways thinking in order for the patient to be successful in making behavior modifications and, ultimately, to help prevent, treat, and reverse chronic disease. At the heart of lifestyle medicine is behavior change, which is grounded in the complex interaction of psychosocial determinants of health, chronic disease processes, and the risks that lead to them. Positive psychology as a movement is emerging as a key pillar of lifestyle medicine because of its role in informing how to promote behavior change. Snyder’s hope theory represents one important concept that has the ability to equip clinicians with a tool set that will allow them to apply positive psychology to their practices of medicine.